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AMPUTATIO N
THE   ENTIRE  LOWER JAW,
f;Xt
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DISARTICULATION OF BOTH CONDYLES.



      BY J. M. OARXOCHAN, M. D.,

PROFESSOR OF TUE PRINCIPLES AND OPERATIONS OF SUUGEIIY IN THE NEW-YORK
   MEDICAL COLLEGE, CHIEF SURGEON TO THE NEW-YORK EMIGRANTS'
               HOSPITAL, &C,

             WITH PLATES.


         [From the Xcw-York Journal of Medicine.]




               ^v Gon/fr-~—=
        New-Work:

VAX NORDEX «fc AMERMAN, PRTXTEItS,
      Xo. CO William-street.
1 8 5 :J .
fi'M

 
 
          AMPUTATION




                   Of





THE  ENTIRE LOWER  JAW,



                   WITH



  DISARTICULATION OP BOTH CONDYLES.



                     /
        BY J. M. CAENOCHAN, M. D.,

PROFESSOR OF THE PEINCIPLES AND OPEEATIONS OF SUEGEEY IN THE NEW-YOEK MEDICAL
    COLLEGE, CHIEF SURGEON TO THE NEW-YOEK EMIGRANTS' HOSPITAL, &C.,

               WITH PLATES.

           [From the New-York Journal of Medicine.]
        JfttD-Dorlt:

VAX NORDEX & AMERMAX, PRIXTERS,

      Xo. 60 WlLLIAM-STREET.
1852. 
 
                DEDICATED


          TO THE PRESIDENT AND MEMBERS

                      OF THE

HONORABLE BOARD OF COMMISSIONERS OF EMIGRATION.

                    ?N NEW-YORK,

                         By their obedtent servant,

                                  J. M. CARNOCHAN.
  $resi&ent ot t&e 3Soartr,
GULIAN C. VERPLANCK

       ^embers,
ROBERT B. MINTURN,
CYRUS CURTISS,
GREGORY DILLON,
CHAS. H. MARSHALL,
FERDINAND KARCK,
Hon. AMBROSE C. KINGSLAND,
Hon. CONKLLN BRUSH,
JOHN E. DEVELIN,
ELIAS HICKS,
JAMES KELLY. 
THE LOWER  JAW-AFTER  MACERATION.
Lith.kPruutd in Colors hy Saj-ouy £
rr  ( o/t i/y/es"  of l/i ef</n
6   Sftt////  of'd/ie jan•- diseased
c-  Body o/ l/ie ,/7/m in a S/a/c <,/',,, ,•/>„.>/. v  ,t/<d -vee/t
    as  Sepa/a*£ed   du/i/tu /A, <ty,e rat /o/t . 
APPEARANCE  OF THE  PATIENT  FOUR  MONTHS  AFTER THE OPERATION

■ '.?■--  ;
Upon t/ie.s'/i/r of 17W. I'ace jtJve deal/it  is- seen, shew tug
t/ie line of t/ie, ,-xter?icU i/tcis/.j/i / a  sim./ltti*
incision made upo7i the opposite side, //teet.y t/ze
other <// die ('/tin 
 
            A  MPUTATIOX

                      OF THK

ENTIRE   LOWER   JAW.
   Notwithstanding the repeated instances on record of large
 portions of the lower jaw having been lost by accident or dis-
 ease, surgeons appear to have been slow in admitting the possi-
 bility of practising amputation, either partial or total, of this
 bone. To Dupuytren was reserved the glory of having, in 1812,
 first removed, by a methodical operation, a portion of the body
 of the inferior maxilla; but since the innovation of the  cele-
 brated French surgeon, the operation for the partial exsection
 of this bone has been repeatedly performed.  In the annals of
 surgery, there is an allusion made to the amputation of the
 entire lower jaw, by "Walther, of Bonn; but I have not been
 able to trace the truth of it to an official source.
  The following case will  prove that  this operation can be
 performed with success;  and that the patient, although de-
 prived of the  chief instrument of mastication, may  survive,
 and enjoy the usual condition of health.
  Mcholas Donegan, aged  43, a farmer by occupation, was
 admitted into  the New-York Emigrants' Hospital, March 7th,
 1851.  He was treated for some weeks, in the Medical Divi-
sion, for typhus fever, and was afterwards transferred to the
Surgical Department, under my charge.   Upon examination
of the  patient, his face presented much tumefaction, and he
complained of great pain, seated chiefly in  the region  occu- 
6
pied by the inferior maxilla.   Upon carrying the examina-
tion further, the lower jaw was found to be extensively affect-
ted with  necrosis.   All the external  appearances denoting a
cachectic condition of the constitution, with extreme  debility
and general prostration of the vital functions, were  present.
The  patient stated that, during  his recent  voyage to this
country, he  had received  a severe blow upon the lower jaw
and side of the face.  This circumstance, coupled with the
cachectic condition following the attack of fever, appears, as
far as can be learned, to have been the origin of the disease
of the bone.
   A tonic course of treatment was prescribed for him, and va-
rious local applications and lotions were resorted to,  in order
to allay the irritation in the mouth, and abate the fetor ema-
nating from the disease.   In  a short time, the teeth became
loose, and had to be extracted; the alveolar ridge became par-
tially denuded; the swelling  increased towards and  over the
rami and condyles; and the patient complained of excrucia-
ting suffering and depression.  Nutritious diet and the various
therapeutic  agents, proper to improve and renovate his sys-
tem, were persevered in ;  and soothing and astringent lotions
and applications were unremittingly used.  This plan of treat-
ment was pursued for about three months ; at the expiration
of which  time, it became evident that the  disease of the
osseous tissue was  too deeply rooted to be affected  by mere
remedial agents.   In fact, they were found to be entirely un-
availing.  The disease had  now apparently seized upon  the
entire jaw; pus was  abundantly secreted into  the  cavity of
the mouth ; the saliva was also thrown out in  great quantity;
and the fetor became almost intolerable to the patient himself,
and to those  around him in the ward.   Constitutional irrita-
tion and hectic of a grave  character had  also set  in; diar-
rhoea made its attack; and the patient was gradually sinking
under the complications of his disease, and  the terrific pain
by which he was unceasingly tortured.  It was apparent to me
that the speedy death of the patient could  only be avoided
by removing the source of such  intense suffering and consti-
tutional  derangement.   The  integuments over the disease,
although much tumefied, oedematous, tense and red, remained 
7
free from ulceration ; the vitiated secretions taking their exit
by the cavity of the mouth.
  On the 13th of July, a consultation was held, and an opera-
tion  for the removal of the bone  decided upon.  The  for-
midable nature of the operation proposed, together with the
debilitated and cachectic condition of the patient, induced me
to enter into full explanations, and to inform him of the great
risk that would attend it.  The matter was then  left to him-
self,  and at his urgent request, I proceeded to use my efforts
for  his relief.  It was  not thought expedient to administer
either chloroform or ether, on account of the liability to as-
phyxia from the passage of blood into the wind-pipe.
  The patient being seated on a chair, and the assistants pro-
perly arranged, an incision was first made, commencing op-
posite the left  condyle, passing downwards towards the angle
of the jaw, ranging at about two lines in  front of the posterior
border of  the ramus, and extending thence along the  base of
the jaw, to terminate  by a slight  curve  on the mesial line,
half an inch below the free margin of  the lower lip.  The
bone was now partially laid bare, by dissecting upwards the
tissues of the cheek, and by reflecting downwards, for  a short
distance, the lower edge of the incision.  The tissues forming
the floor of the mouth, and situated upon the  inner surface of
the body of the bone, were separated from their attachments
from a point near the mesial line, as far back as the angle of
the jaw.  The attachments of the buccinator were next divided.
The  facial artery, the sub-mental and the sub-lingual, already
cut, were then secured by ligature.   It was now seen that the
bone was  partially separated at the symphysis, and that the
necrosis was complete from that point to the inferior portion
of the ramus.   The ramus itself was found diseased ;  the pe-
riosteum externally was inflamed, and in some parts easily
detached.   The  tongue was now grasped and held forwards,
while the attachments  of  the genio-hyo-glossi muscles were
divided.   A double ligature was passed through the anterior
part of the root of the tongue, and  entrusted  to an assistant,
in order to prevent its  retraction upon the superior orifice of
the larynx.  A fatal case from the falling backwards of the
tongue, occurred a few years ago, in  the practice of an emi- 
8
nent surgeon of this city; and a similar  misfortune should
always be guarded against, when the muscular attachments
of the tongue to the posterior part of the bone behind the
symphysis are divided.   A slight force exercised upon the left
half of the body of the jaw, broke the connection at the sym-
physis and at the angle, and this part was easily removed.
The next  step  consisted in  the  removal of the left ramus.
The external  surface of the branch of the jaw, and of the tem-
poro-maxillary articulation were  exposed,  by dissecting the
masseter upwards, as far as the zygomatic arch.  Seizing the
ramus in order to pull the coronoid process downwards below
the zygoma,  it  was found  that the temporal muscle was
rigidly and permanently retracted.   This  circumstance pre-
sented an unexpected difficulty, which was  increased by the
unusual development of this apophysis, and by the retraction
also of the pterygoid muscles.  Passing the forefinger  along
the inner aspect of the ramus, the  situation of the internal
and external carotids was  sought for  and recognised.   The
insertion of  the pterygoideus internus  was then  felt and
cut, grazing  the bone in doing  so;  the lingual nerve, here
in close  proximity, being carefully avoided.   Passing still
higher up, the orifice  of  the  dental canal,  indicated by
an  osseous projection,  could  be felt; and the instrument,
still guided  by the finger, divided the  dental  artery and
nerve.  The knife was thus  made to separate the tissues
attached to  the inner face  of the  bone,  as high up  as a
point situated  about  a line below  the  sigmoid notch,  be-
tween the condyle  and the coronoid  process.   On  a  level
with  this  point, at the posterior margin  of the ramus,  the
transverse facial, internal  maxillary  and temporal arteries
form a kind of tripod, the two last named branches of  which
should not be divided, if possible.  It now  became necessary
to detach the tendon of the temporal  muscle.   As the coro-
noid  process could not be depressed, I proceeded cautiously,
by dividing the lower attachments of  the tendon, by means
of blunt curved scissors; and by using them  and a probe-
pointed bistoury, alternately—keeping close to the bone—
a considerable portion of the tendon was divided.   Deeming
it not prudent to use freely a sharp  cutting instrument, deep 
9
in the temporal fossa, where the coronoid process was situ-
ated, I made use of a pair of bone scissors, curved flatwise ;
and by passing the blades of this instrument over the process,
as far as its position would  permit, the temporal muscle was
detached; a small  portion of the apex of the coronoid pro-
cess  being cut through.  The  ramus, now movable,  could
be made use of as a lever to aid in the disarticulation of the
bone.
  In order to effect safely the disarticulation of the condyle,
I began  by penetrating into the joint, by cutting the liga-
ments from  before backwards,  and from without inwards.
The articulation was thus opened sufficiently to allow the con-
dyle to be completely luxated. Blunt-pointed scissors were now
used to cut carefully the internal part of the capsule and the
maxillary insertion of the external pterygoid muscle; and by
a slow movement of rotation of  the ramus upon its axis, the
condyle was detached, and the operation was completed on
this side.  By proceeding to disarticulate by the method here
described, injury to the temporal artery, as well as to the in-
ternal maxillary, was avoided.
   To effect the removal of the other half of the lower jaw, the
same incision was made on the opposite side, so as to meet
the first on the mesial line.  The dissection was also similar;
and by disarticulating the  second condyle in the same man-
ner as had been observed for the first, I was successful again in
avoiding lesion of the temporal and internal maxillary arteries.
   The annexed plate, No. 1, is a correct delineation  of the
inferior maxilla, after maceration, and exhibits  the portions
of the bone as they became separated during the operation.
   The object I had in view, in shaping the external incisions,
in such a way that an inverted V should be formed in front of
the, insertion of the genio-hyo-glossi muscles, was  to leave a
portion of integument so fashioned, that the suture-pins could
be passed  through the integument, and, at  the  same  time,
through the root of the tongue, at the point where its muscles
had  been detached from the inner surface  of the jaw.  The
several tissues  becoming thus incorporated in the resulting
cicatrix,  served to form a new bridle, somewhat analogous to
the natural muscular attachments of the tongue to the genial
processes. 
10
  The amount of blood lost was inconsiderable;  the  arteries
divided, besides those mentioned, were the transverse facial,
the anterior masseteric, the anterior parotidean, &c.; and these
were secured as soon as divided.  The bone being disarticu-
lated, the flaps were  adjusted,  and the lips of  the  incision
united, by eighteen points  of twisted suture.  The tongue
was retained forwards after the dressing, by attaching the
ends of the ligature already passed through its base, on  each
side, to a bandage passed vertically around the head.   Forty-*
eight  hours after the operation, the first dressing was re-
moved. Union by first intention had taken  place, and eight
of the  suture-pins were  taken out.   In  ninety-six hours, the
wound was  again  examined.   Union was found to be en-
tirely completed, and the remaining pins were removed.   On
the seventh day, it was thought safe to  remove  the  ligature
from the  tongue.   On the tenth day, the arterial ligatures
came away; and on the fourteenth day, the patient was pro-
nounced cured;  not having had an untoward symptom since
the performance of the operation.
  The operation occupied fifty-five minutes,  the patient  hav-
ing been allowed intervals of repose to recruit.   It was per-
formed in the presence  of a number of professional gentle-
men ; and  I was ably assisted by  my colleague, Dr. A. V.
Williams, by Drs. Dewees and Dixon, of New-York, and by
Drs. Thompson, "Whitehead, Smith  and Bailey, resident as-
sistants attached to the surgical staff of the Hospital.
  The present appearance of the patient, upon  reference to
the accompanying  plate, No. 2, will be seen to present much
less deformity than might be expected from the  severe muti-
lation which he  has undergone.  His general  condition and
health are good; and he is now able to perform any ordinary
vocation.  The ducts of Steno, on both sides, were necessarily
divided in the superficial incisions;  but there is no salivary
fistula, the saliva taking  its course into  the  mouth.  The di-
vision of the branches of the facial  nerve has not been fol-
lowed by paralysis of the face;  although for a time  after the
reunion of the incision, the orbicularis  palpebrarum of the
right side appeared to have lost its action to some extent.  In
grasping the chin, a thin cartilaginous deposit  can now be 
11
felt, extending, crescent-shaped, for about three inches, and
occupying the position at which the bone was most diseased.
Higher up, toward the glenoid cavity, no deposition of bone
or cartilage has  taken place.   Injury  to  the bag of the
pharynx, during the detachment of the soft tissues from the
angle of  the  jaw, was carefully avoided, and fluids could be
swallowed, in small quantities, immediately after the operation.
Deglutition is now effected without difficulty.   Articulation
is sufficiently distinct to render his  words intelligible, and
although unable to masticate, he does not complain of difficulty
in eating, breaking up, as he says he does, his  food  between
the tongue and the palatal vault of the superior maxillae.

   New-York, 759 Broadway, Dec. 1851.