CYSTIC TUMORS OF THE JAW. 
By J. MASON WARREN, M.D. CYSTIC TUMORS , OF THE JAW. 
By J. MASON WARREN, M.D. 
Read at the Annual Meeting of the Massachusetts Radical Society, 
May 29,1866. . qC A G ‘ ’rS . 
The appearance of these tumors is generally very formidable, and 
the practice, for the most part, when the whole substance of the bone 
is dilated into a mere sac, almost entirely deprived of osseous sub- 
stance, has been, until very recently, to remove the portion of the 
jaw involved by the tumor. When the tumor has grown simply at 
the expense of the outer table of the bone, either of the upper or 
lower jaw, without involving its whole substance, it has been 
customary to explore the cyst and remove a portion of it, caus- 
ing inflammation and obliteration of the cavity, as in the case of 
cysts occurring in soft parts. Dupuytren, in his collected articles 
on Diseases of the Bones, has attached more importance to this 
question than any other writer, and illustrates by cases the effect of 
exposing the tumor by external dissection, removing a portion of the 
sac, and, by applications, effecting its obliteration. Professor March, 
of Albany, has written a valuable paper on this subject, in the “ Trans- 
actions of the New York State Medical Society.” Professor Gross 
and others have suggested the idea fliat in large cysts, which involve 
the whole bone, and which formerly were known under the name of 
“ spina ventosa,” the treatment should be the same. In one of the 
cases cited by the former gentleman, the extirpation of the bone was 
finally found necessary after this plan had been tried. 
As to the causes of these diseases, they are various. In the jaw> 2 
CYSTIC TUMORS OP THE JAW. 
they probably arise, in most instances, from irritation at the roots of 
the teeth; in the long bones, the head of the tibia for instance, from 
blows. 
In 1862,1 published, in the Boston Medical and Surgical Journal, 
a case occurring in an elderly woman of a cyst which involved the 
ascending portion and condyles of the jaw, and which I removed; 
not thinking it safe, in a person of her age, when the disorganization 
of the jaw seemed to be so complete, to run the risk of an experi- 
mental mode of treatment. Since that time, I have had an oppor- 
tunity of trying the conservative plan of treatment in two instances, 
which I propose shortly to relate. 
Notwithstanding the principle which has been suggested or hinted 
at, for the treatment of large cystic tumors of the jaw, none of the 
writers on the subject have presented cases—where complete destruc- 
tion of the bone has taken place, leaving nothing but a delicate cyst— 
which have been successfully treated by the method referred to. Du- 
puytren, in his work on “ Diseases of the Bones,” gives several cases 
treated without excision; some of them, however, unsuccessfully. 
M. Nelaton has also written upon the subject, referring for cases to 
the work of Dupuytren, and advising the puncture of the cyst and 
the stuffing of its cavity with lint. Mr. Erichsen says, 11 when the 
cysts are so large that they have destroyed the integrity of the bone, 
or when they are associated with a large quantity of fibrous tissue, 
so as to constitute true fibro-cystic tumors, excision of the diseased 
bone must be practised.” Mr. Stanley, in his u Treatise on the Dis- 
eases of the Bones,” describes perfectly the affection, but does not 
allude to any other operation than the u removal of the tumor and of 
the portion of the bone from it has arisen.” 
In the two following cases, the treatment consisted in the punc- 
ture of the sac within the mouth, evacuating its contents, and at the 
same time obliterating its cavity by crushing in its walls; and lastly, 
in keeping up, by injections, &c., a sufficient degree of irritation to 
favor the deposition of new bone. The comparative mildness of 
this mode of treatment, and the excellent character of the results CYSTIC TUMORS OP THE JAW. 
3 
combine to award the preference for this operation over excision, or 
even the large external incision adopted by Dupuytren. 
Cystic Tumor of the Lower Jaw. 
Case I.—A young woman, set. 25, with light hair, blue eyes; 
and delicate skin, applied to me, in the spring of 1862, on ac- 
count of a large tumor involving the whole right side of the jaw 
above its angle. The tumor was of a globular shape, extended 
back under the lobe of the ear, forwards so as to encroach 
upon the cavity of the mouth, and upwards so as to press upon and 
somewhat to overlap the zygoma. The external surface of the tu- 
mor was smooth and shining, slightly oedematous, and she suffered 
somewhat from its pressure upon the surrounding organs. It had 
commenced, some years before, by a swelling at the root of the wis- 
dom tooth of the right side, and the inconvenience caused by its 
pressure had become so great as to lead her to take measures for its 
removal. 
Upon consultation, it was decided that a portion of the jaw would 
probably require removal, the tumor having been first exposed by an 
incision made inside of the mouth, to verify its character. 
The following operation was performed, under the influence of 
ether. An incision was made in the most prominent part of the tu- 
mor in the mouth, upon which a large quantity of glairy fluid escaped. 
Upon passing the finger into the opening, it was found that the whole 
jaw, at this point, with the articulating and coronoid processes, was 
expanded into a mere shell, at some parts as thin as parchment, and 
destitute of osseous substance. It was without solid contents. Un- 
der these circumstances, and considering the good health and youth 
of the patient, it was determined to make the attempt to save the 
jaw. A portion was therefore removed from the sac, and with the 
fingers the sides of the cavity were made to collapse, so as to come 
in contact with each other. In order to excite still further irritation, a 4 
CYSTIC TUMOES OF THE JAW. 
bit of cotton cloth was forced into the interior, and the end left pro- 
jecting into the mouth. A moderate degree of irritation followed, 
and in a day or two the pledget was removed, suppuration hav- 
ing commenced in the sac. The aperture was dilated from time 
to time by the introduction either of the finger or of a bougie, 
and the sac injected with tincture of iodine. In two or three weeks 
she left the Hospital, with the tumor reduced to about half its origi- 
nal size. From that time until the present, she has occasionally 
visited me at my house, and by keeping the external opening free, and 
occasionally irritating the interior of the sac, a solid mass of bone 
has been deposited anew, and the jaw has resumed somewhat of 
its original shape. The sac is in the way of becoming entirely 
obliterated. 
In November, 1863, I again saw the patient, who came to consult 
me, not about herself, but about a friend. All signs of the tumor 
were gone, and the jaw had regained almost its natural shape; but 
a small aperture still existed at the site of the former opening 
into the mouth, from which a glairy fluid was occasionally discharg- 
ed. She was quite well, and all the functions of the jaw were per- 
fectly performed. 
Subsequently, she applied to me with a similar tumor, but of a 
much smaller size, which had appeared anterior to the site of 
the first one. It was treated in a similar manner, with a similar 
result. 
Case II.—May 23d, 1863, Dr. Bennett of Uxbridge, Mass., brought 
me as a patient, a gentleman 56 years of age, with a large tumor on 
the right side of the face and, parotid region, j He was of a pale 
and yellowish color, much emaciated, and his aspect at first struck 
me as that of a person suffering from malignant disease. He said that, 
five years before, while eating, he had the sensation of something giv- 
ing way in the neighborhood of the ascending ramus of the lower jaw. 
Shortly after, a tumor appeared in that region, which had slowly in, 
.creased to its present size. Before making an examination, it was CYSTIC TUMORS OP THE JAW. 
5 
not easy to say whether the tumor was connected with the parotid 
gland or with the jaw. From the first commencement of the tumor 
to the present time, mastication, and for a good part of the time, 
deglutition, had been much interfered with. The tumor had been 
examined by many physicians of experience, and by most of them 
considered as a parotid tumor, and, as the patient inferred, although 
he was not directly told so, of a malignant character. It extended 
backwards into the parotid region, upwards upon the face, and in- 
wards, so as to occupy the right half of the palate, and was covered 
with a highly irritable mucous membrane, somewhat cedematous, and 
similar to what we often see investing malignant tumors in the mouth 
which have made their way through from the neck. During an exa- 
mination, the patient said there had been of late a slight discharge 
of fluid into the mouth, and on making a careful inspection, a minute 
aperture was detected, at the point where the last molar tooth had 
been removed. 
On introducing a probe at this point, a jet of serum, mixed with 
flakes of lymph, was projected to a considerable distance. I imme- 
diately enlarged the opening with the knife, so that I could intro- 
duce the finger. This was a matter of some difficulty, however, as 
the patient’s jaws had been for a long time nearly closed in conse- 
quence of the disease. The finger penetrated into a large sac ex- 
tending far out of reach, and on investigation it soon became evi- 
dent that the whole tumor was formed by the expansion of the jaw 
from the development within it of an immense cyst. On withdraw- 
ing the finger, a barrier of bone was felt extending across the jaw, 
and behind it, under the first molar tooth, another smaller sac was 
discovered. 
I now decided to treat this case in a similar manner to the pre- 
ceding one. An oblong piece of about an inch in length and half an 
inch in width was removed by scissors, from the wall of the cyst, 
and, with a finger of one hand in the mouth, and a finger of the 
other on the outside of the face, the sides of the cyst were broken 
down, giving way under the pressure like parchment, with a crepitat- 6 
CYSTIC TUMORS OP THE JAW. 
ing noise. The projection of the tumor on the face, as well as with- 
in the mouth, became in a great measure effaced. There was a slight 
but unimportant effusion of blood. The patient returned home under 
the charge of his physician, with the intention of pursuing pretty 
much the same course as was adopted in the former instance. On 
account of his age, and the debility caused by the want of proper 
nourishment, and owing to the difficulty of mastication, he was or- 
dered tonics and a nutritious diet. 
About four weeks later, I again saw him. Everything had gone 
on well. The tumor was not more than a fourth as large as former- 
ly, and bone had begun to be deposited in the walls of the sac. His 
health was wonderfully improved, and his complexion had assumed 
a healthy hue. 
Dec. 8th, 1863.—I saw him for the third time, so altered for the 
better as scarcely to be recognized as the same person. The jaw 
externally had resumed its natural shape, and, on examination with 
the finger, its distinctive anatomical marks and processes could be 
felt. On the inside, where the incision had been made, a deep 
sulcus was observed, lined with mucous membrane, into which a 
probe could be passed into the ascending ramus. There was no dis- 
charge to be detected, and the power of mastication was as good as 
ever. The only trouble he experienced was from the lodgment of 
food in this cavity. 
Three months later, he was seen with the jaw in a perfectly 
healthy condition, having all its functions, and the only change from 
the normal state was perhaps a somewhat more and thickened 
condition than natural, with a sulcus existing at the back part, 
where the tumor had originated. 
In 1866, he made me a visit, for the purpose of showing the com- 
plete success of the operation. 7 
CYSTIC TUMORS OP THE JAW. 
Cystic Tumor of the Upper Jaw. 
Case III.—A young lady, set. 16, of English parentage, was brought 
to me in May, 1865, on account of a tumor which had been develop- 
ing for the last three years, in the alveolus of the right upper jaw, 
just above the canine and bicuspid teeth. Three years before, the 
nerve of the canine tooth had been destroyed by arsenic, and the 
carious cavity filled with gold, the first bicuspid also being filled at 
the same time. Irritation soon commenced at the roots of these 
teeth, and gradually, and almost imperceptibly, a swelling appeared 
there. A month before she came to me, this tumor opened at its 
most dependent part, discharging a glairy fluid, which continued to 
exude until I saw the case. 
The aperture admitted a small probe, which penetrated into a 
deep, smooth cavity. With the finger, the tumor from below appear- 
ed firm; but, when pressed 'upon under the gum, a degree of elasti- 
city was distinguished. 
I informed the parents of the young lady that the disease was a 
cystic tumor of the bone, and advised an operation. This was as- 
sented to. The patient was etherized, and a cut made into the tumor. 
The mucous membrane was then dissected up from its surface, so as 
to expose so much of the bony sac as would admit of a free opening 
being made into it, and the portion of bone was removed with scis- 
sors. The finger could now be passed freely into the cavity, which 
was quite smooth and entirely lined with membrane; it was not 
penetrated by the roots of any of the adjacent teeth. The cavity 
was stuffed with lint, in order to excite inflammatory action, for the 
purpose of obliterating the sac. 
The operation had all the effect that could have been desired. In 
the course of a couple of months, granulations filled up the cavity, 
entirely obliterating it. She was completely relieved of the disease. 
One or two other cases of cysts in the upper jaw I have treated in 
the same way, with a similar result.