Multilocular Cystic Tumor of 
Inferior Maxilla.* 
Surgical Clinic, January, 1897. 
Professor of the Principles and Practice of Surgery and Clinical Surgery in Memphis 
Hospital Medical College, Memphis, Tenn. 
W. B. ROGERS, M.D. 
Gentlemen — I present you today a case of unusual inter- 
est— first, because of the size to which the growth has been 
allowed to attain in this day of surgical advancement ; sec- 
ond, it illustrates how much destruction may be caused by 
a tumor which is in itself nonmalignant; again, it empha- 
sizes to you the truth of the rule I have often repeated to 
you—“ All tumors should be removed while yet small.” 
Nathan Watson, 38 years old, residence Mississippi. Eight 
years ago he had large tumor on right half of body of lower 
maxilla, and which I removed at this clinic. No notes were 
kept, and I am unable to say now what was the nature of the 
growth, but the line of incision, you will see, still marks the 
lower lip, just to the right, lie recovered promptly from the 
operation, and the parts remained well for five years. 
Three years ago the present growth began on the right side 
and extended to the left; it progressed slowly until about a 
year ago, since which time it has increased more rapidly to its 
present dimensions. Examining we find the tumor involves 
and has destroyed the entire body of the bone. The outline of 
each ramus we readily trace from its temporal articulation to 
* Reprinted from Memphis Medical Monthly, May, 1897. 2 
Rogers: Surgical Clinic. 
the corresponding angle, and then the outline of the jaw loses 
its identity in the bulging mass. Inspecting the oral cavity, 
we find it occupied in toto by the growth, and the tongue so 
pressed down and backward that its tip cannot be put forward 
to within two and a half inches of the upper incisor teeth. The 
lower teeth are irregularly scattered from their normal sites, 
loose and impossible of being opposed to the upper ones. No 
food can be masticated; nourishment is confined to liquids 
and mushy substances. Raising the chin the mass is seen to 
depress the hyoid bone and thyroid cartilage very markedly. 
Articulation is difficult and very indistinct. General health, 
you see, is poor; debility is marked, and for a year he has had 
No. 1. Nathan Watson—Multilocular Cystic Tumor of Inferior Maxilla. Rogers: Surgical Clinic. 
fevers recurring every few days and uncontrollable by quinine. 
With this much of the history and examination, let us con- 
sider the case from a clinical standpoint. Is the growth ma- 
lignant or not? Carefully examining the tumor on its cuta- 
neous aspect, as well as mucous, I find skin movable and 
nonadherent; mucous membrane closely adherent, but not 
disintegrated nor infiltrated by the growth; no enlarged veins, 
no enlarged glands, no oedema, no extension of disease beyond 
the bone in which it began, no destruction of tissue outside of 
the former bony envelope except by pressure; a displacement 
of surrounding parts, but no involvement of their tissues; 
locally no signs of malignancy; the only symptoms of malig- 
No. 2. Nathan Watson—Multilocular Cystic Tumor of Inferior Maxilla. 4 
Rogers: Surgical Clinic. 
nancy are the fever and emaciation. The loss of seventy 
pounds in a year may in part be attributed to inability to 
take proper nourishment; and the fever, while septic in char- 
acter, may be due to diseased conditions coming on in other- 
wise nonmalignant growths. All tumors are composed of 
cells seen in the human body; the tissues of a tumor are 
functionless, and of a low grade of vitality ; the normal reg- 
ulators of nutrition (nerves) are wanting in tumors. Hence, 
as I have often called to your attention, tumors are liable to 
diseases (abscess, cheesy degenerations, disintegrations, cysts), 
and may become infected and poisoned as other healthy tissues 
do; and thus the fever is not of necessity a sign of malig- 
nancy in this case. Three years ago the tumor began, and 
surely in that time some local signs of malignancy should 
have presented. He suffers much pain, but that, I believe, 
comes from tension within the growing mass. Considered 
from every standpoint, I should look upon this as a non- 
malignant growth. 
Is it solid or cystic in structure? Palpating it we find nu- 
merous soft, elastic points separated by hard points or depres- 
sions; fluctuation is not distinct, and on the whole the mass 
is quite hard and resistant. Here I will puncture one of the 
soft spots, and you now see a discharge of brownish fluid, of 
the consistence of the white of an egg. My finger, inserted, 
outlines a cavity with capacity of half an ounce, and detects 
a soft point on the partition wall. The tumor, then, is evi- 
dently not solid, but cystic, and made up of many cysts. It 
is a multilocular tumor, or compound cystic tumor. 
You ask, What is the origin of such a growth ? Well, cys- 
tic tumors of the bone are sometimes due to a tooth (usually 
permanent) defective in development, or misdirected, so that 
it never reaches the surface of the alveola, and the follicle sur- 
rounding the crown is the source of the cystic tumor — an Rogers: Surgical Clinic. 
5 
exudation cyst—always a single sac tumor. Small cysts orig- 
inate at the fang (point), and may become large—a single sac 
tumor. Multilocular cysts of the inferior maxilla are not usu- 
ally proliferation cysts, but are formed as other new-formed 
sacs — i. e., a congestion occurs from cold or injury, or from 
an adjacent diseased tooth, and effusion or hemorrhage into 
connective tissues (cancellous tissue) follows; this, as an irri- 
tant, produces a surrounding cover of fibrous material, which 
goes to form a cyst or sac. And lastly, multilocular cysts are 
said to be formed by an ingrowing of epithelium from the 
mucous membrane on the alveola. 
Is operation justifiable? And how extensive should it be? 
His condition is bad, pulse 100, temperature 100°. I have had 
him under treatment hoping to improve it, but without suc- 
cess; and if operation is to do good, delay will not enhance 
the chances. I have satisfied myself that all bony substance 
has been destroyed by pressure, and this mass is composed of 
cysts separated by heavy fibrous partitions. It would do no 
good to try to leave any outline of a jawbone, and I shall 
remove the entire mass from angle to angle. 
The dangers attendant on operation in this case are suffo- 
cation by blood running into windpipe, shock, and afterward 
septic infection. 
Without operation. 
Death from exhaustion—due to 
Sepsis 
or 
Suffocation. 
Prognosis. 
a, Suffocation caused by blood' 
getting into the trachea. 
both preven- 
table by pre- 
" liminary tra- 
cheotomy. 
With operation 
Death may 
occur from 
b, Shock due to 
Loss of blood 
or prolonged 
anesthesia 
or 
Recovery. 
c, Sepsis—prevented by drainage, cleanliness 
Tracheotomy. The administration of ether or chloroform in 
the usual way in this case would be attended by no little risk, 
and I shall do a tracheotomy under cocaine anesthesia, and 
follow with chloroform, inhaled through the tracheal wound, 6 
Rogers: Surgical Clinic. 
for the main operation. Chloroform will be less likely to pro- 
duce bronchitis than ether administered so directly into the 
lungs. (The patient was placed on his back, and head thrown 
far backward; the greatest distance attainable from sternum 
to thyroid cartilage was one and three-fourth inches. It was 
with much difficulty that high tracheotomy was safely done, 
and a soft rubber catheter was passed into the windpipe. By 
this means the anesthetist was placed where he would not 
conflict with the operator or assistants, thereby admitting of 
continuous, even administration of the anesthetic, and of a 
more rapid performance of the operation on the tumor, les- 
sening loss of blood and shock.) 
Excision of Tumor. An incision was begun on the lower lip, 
following the old incision, down to well under the tumor, 
three and a half inches, and thence another to the right about 
three inches. The two flaps were then turned downward and 
outward. The tumor was cut into, and upward of twenty 
cysts evacuated of their contents, varying in consistency from 
water to mush, and of various colors. A few pieces of bone 
disconnected were found and removed. The entire fibro-cys- 
tic mass, with its posterior limiting wall, was removed from 
angle to angle; only two ligatures were found necessary. 
The flaps were brought together with silk gut sutures, and 
drainage left below. 
Eight weeks later patient was presented to the class; had 
gained seventeen pounds, and was enjoying excellent health ; 
articulation distinct. Rogers: Surgical Clinic. 
7 
No. 3. Nathan Watson—Eight Weeks After Removal of Multilocular Cystic Tumor 
(Including Body of Lower Jaw from Angle to Angle).