Abstract: A series of pre-operative casts of the head, one of plaster of Paris and the other of wax, have recently been discovered in the Department of Anatomy, Edinburgh, of a patient with an immense tumour of the left maxillary antrum which produced an enormous degree of facial distortion. These casts complement a series of engravings published in the contemporary literature. This lady's tumour was successfully excised by Robert Liston in 1834 in the Royal Infirmary of Edinburgh, only a month before he left Edinburgh for London. The tumour was believed to be benign, and was removed without the benefit of anaesthesia. The patient returned the following summer to have a gold palate fitted, and while her voice was initially indistinct, it subsequently recovered.
Key words: Excision of facial tumour; maxillary antrum; Robert Liston; pre-anaesthetic era.
Background
The clinical case reported here is of considerable interest in several regards, principally because it was, in 1834, the largest facial tumour of its type that Robert Liston (1794-1847) had encountered, and secondly, because he operated on this patient and successfully removed the complete tumour, only about a month before he left Edinburgh for London. He had been appointed to a senior surgical post at the recently established North London (now University College) Hospital, a hospital then associated with the University of London, and in the following year he was offered, and accepted, the Chair of Clinical Surgery in the University of London, at University College. It was in this hospital in December 1846 that Liston performed the first amputation under ether general anaesthesia in Great Britain.(1)
While Liston had for many years been regarded as one of the finest surgeons in Edinburgh, his uncompromising personality was such that he had been involved in difficulties with his anatomy teacher and mentor, Dr John Barclay, his distant cousin, James Syme, and with the Managers of the Royal Infirmary of Edinburgh, so that his relationship with all of these was rarely less than tempestuous. When James Syme (1799-1870) was offered the Chair of Clinical Surgery vacated by James Russell in 1833,(2) it is likely that, out of pique, Liston would have accepted any senior surgical post that was offered, as long as it was outwith Edinburgh. Liston was generally expected to be Russell’s natural successor, but he had refused to accept the conditions that were associated with this post.
Both Liston and Syme gained considerable reputations for their operative dexterity and skill. Their early clinical careers closely paralleled each other, and at times even overlapped. After his brief spell in London, in 1816, at St George’s Hospital, where he gained his MRCS diploma, Liston returned to Edinburgh, and in 1817 was appointed Barclay’s principal demonstrator.(3) The following year, after a difference of opinion with Barclay, he established a small rival extra-academical school, with Syme, who at that time was only in the second year of his medical studies, acting initially as his demonstrator and later as his assistant.(4) During the same year, Liston was awarded the Fellowship diploma of the Royal College of Surgeons of Edinburgh.(5) It is probably a reflection of Liston’s almost reckless character that he was also a fearless resurrectionist, and various descriptions of his exploits in this regard have been published.(6)
Syme had also begun his medical career as a pupil of Barclay, attending his anatomy class in 1817; in 1821, he became a member of the London College of Surgeons (MRCS), and was later elected to a Fellowship of that College in 1843, as one of the original 300 Fellows.(7) In 1823, when Liston gave up teaching anatomy, Syme took over the class on a full-time basis, having, during that year, also become a Fellow of the Royal College of Surgeons of Edinburgh.(8) Both presented dissertations before the Royal Medical Society, Liston, in 1820, on Fracture of the neck of the femur, and Syme, in 1821, On caries of the bones.
Liston’s surgical career at the Royal Infirmary was initially extremely successful, controversial, albeit brief. He had the reputation as an impressive operating surgeon and an excellent teacher, yet disagreements with the hospital authorities concerning patient care led to a lengthy period of expulsion from that Institution.(9) Despite their earlier reservations, in 1827, Liston was again appointed to the surgical staff of the Infirmary.
His career in London was as impressive as it was in Edinburgh, and in 1840 he was elected to Membership of the Council of the Royal College of Surgeons of England, and in 1846 elected to their Board of Examiners. In 1841, he was elected to the Fellowship of the Royal Society. He died of aneurysm of the arch of the aorta, which obstructed his trachea, in his 54th year, in December 1847.(10)
Operations involving excision of the upper or lower jaw undertaken by Liston and Syme
Both Liston and Syme were clearly exceptionally gifted surgeons, and were prepared to operate on individuals with large tumours involving either the upper or lower jaw which other surgeons considered to be inoperable. Liston published an impressive series of his own cases in the Medic-Chirurgical Transactions in 1837,(11) including that of Mrs Fraser (see below). He also discussed the range of pathological conditions likely to be encountered, and their possible aetiology, in his popular text-book entitled Practical Surgery.(12) Syme, in his Contributions to the Pathology and Practice of Surgery, which was published about ten years later,(13) exclusively concentrated on his experience involving the excision of the lower jaw, in his chapter on this topic. He drew particular attention to the technical problems he encountered in the excision of an enormous tumour of the mandible in what later became known as the "Penman case".(14) No examples of excision of the upper jaw are discussed in Syme’s Contributions to the Pathology and Practice of Surgery, nor is there more than a passing mention of the tumours of this region in any of the editions of his Principles of Surgery,(15) although, in 1829, it has been stated that he excised the upper jaw for the first time in Great Britain, no report has yet been located to confirm this contention.
The principal aim of Liston’s article entitled Observations on some tumours of the mouth and jaws was to draw attention to those tumours in this region which he believed could be removed by operative means, and those which he considered to be inoperable. Of the latter class, he included tumours with a "malignant tendency", where from the history it appeared that the tumour had spread to involve neighbouring parts, particularly the lymphatic system. All of these had a poor prognosis. He considered the various types of "tumours" that may be encountered in this region, including abscesses, as these were often associated with the roots of ‘decayed’ teeth. He also considered the epulis, a solid tumour of the gum, which usually appears between the teeth, being often firmly adherent to the periosteum. In Liston’s article, he reviewed the literature, discussing in particular 15 cases involving extirpation of the whole or greater part of the maxillary bone. Eleven of these patients died, either from the immediate effects of the operation, or from a return of the disease.
Other tumours with a poor prognosis were believed to originate in the alveolar processes or sockets, and often spread to the lining of the maxillary antrum, or even more widely. This group needed to be distinguished from other tumours of the maxillary antrum, which were of a simpler and more amenable nature. These were the fibrous or fibrinous tumours. These were generally traceable to some external injury, and were also comparatively slowly growing. According to Liston, those tumours of this type involving the lower jaw tended mostly to be benign, whereas those of the upper jaw tended to be malignant. However, occasionally, exceptions were encountered, such as Mrs Fraser’s tumour (see below) which was believed to be of this variety.
"They attain, though slowly, a great size, they present a globular or botryoidal (i.e. nodulated) form, displace the surrounding soft and hard parts, project from the countenance and, deranging the features, produce great and frightful deformity".
The case of Mrs Fraser, aged 40, from Banchory Ternan, Aberdeenshire
Mrs Fraser, aged 40, was operated on by Robert Liston in 1834, about a month before he moved to London, and about a year before he was offered and accepted the chair of clinical surgery in the University of London, based at University College.
This lady was admitted to the Royal Infirmary on 13th October 1834 under the care of Mr Liston, having been sent to him by her local surgeon at Banchory. According to the account of the case published in the Medico-Chirurgical Transactions,(16) about six years previously she had received a blow in the region of her left maxillary antrum from the head of a child she had been holding. A hard mass developed in the region where she received the blow, and after about two years this increased in size to form a distinct mass, and during the following two years it rapidly increased in size. At this point she became pregnant, and the tumour continued to increase in size, particularly during the second half of gestation, though the mass was at no time associated with much pain. A year later, she again became pregnant, but her periods failed to return after her delivery. She did, however, mention that the tumour appeared to become more vascular after her menstrual periods, and that when she was unwell there was some bleeding from the unbroken surface of the gums and from the inner surface of the tumour.
According to Liston:(17)
"The left side of the face is completely occupied by an immense growth, which obstructs the eye of that side, rising to a level with the forehead, extending back to the ear, and bulging down below the inferior maxilla, but not attached to it. From the part of the tumour next to the ear to that part in front of the face it measures about nine inches. The mouth is completely drawn to the left side, and there is constant discharge of saliva from it. She keeps a handkerchief constantly applied to it by the hand, to concentrate the sound of her voice when speaking, and to collect the saliva. She is unable to open her mouth above three-fourths of an inch. The tumour bulges considerably into the cavity of the mouth, but there is no difficulty in swallowing. The nose is also twisted to the left side, but she can breathe through it pretty easily. . . . Numerous large veins are seen beneath the integuments of the tumour, and arteries of considerable size are felt beating in it".
It is difficult to do justice to the enormity of the facial distorsion seen in this woman, and Liston’s brief description is accompanied by an engraving showing her appearance. A left fronto-lateral view of the same patient was used by Liston to illustrate the appropriate section on tumours of the upper jaw in his Practical Surgery.
The Anatomical Museum of the University of Edinburgh possesses two important life masks that fully display the enormity of the tumour, and the grave distortion it caused to Mrs Fraser’s face. The uncoloured plaster of Paris life mask in the Ballingall Collection. . . (The details in the 1855 Catalogue are as follows:(18)
"B. 36. Cast of a head very much distorted towards the left side by an enormous tumour of the antrum, which was removed by Mr. Liston. - See a paper on tumours in the "Medico-Chirurgical Transactions" vol. xx. page 186. Presented by Robert Liston, Esq.")
. . . has the advantage that it provides a three-dimensional image which may be viewed from all directions. Very recently, a wax impression almost certainly made from the same negative mould has been located, and, fortunately, bears much of its original colouring. This provides a much more realistic impression of the facial features of this woman shortly before the tumour was removed, than the plaster of Paris life mask, as the blood vessels that course just beneath the surface of the tumour are accurately highlighted. This specimen appears in the Catalogue of the Specimens in the Anatomical Museum,(19) associated with the following information:
"Os. G. 1. 12 (596). A cast in wax of an enormous fibro-sarcomatous tumour, springing from the antrum of Highmore [the maxillary antrum], which was removed by Mr Liston in the Royal Infirmary."
Liston described the operation to remove the tumour in the following terms:(20)
"An assistant being ready to compress the common carotid [artery], the soft parts were divided by an incision which traversed the mesial surface of the tumour, and terminated in the angle of the mouth. The alveolar process (the two central incisors having been previously extracted), the palatine plate, and the nasal process of the maxilla were then cut with the forceps. An incision was carried along the upper surface of the tumour under the inferior eyelid to over the junction of the malar and frontal bones, and prolonged from that, in the line of the zygoma, to near the auricle. The bones were then cut, into the spheno-maxillary fissure and through the zygomatic arch, - all this was done with but little interference with the vascular supply. The connection being loosened, and the tumour shaken to its base, the soft parts underneath were divided, and the mass was turned out without difficulty.
... the bleeding vessels were secured. Nothing interrupted her recovery, and the deformity is much slighter than would be imagined. The patient returned the following summer to have a [gold] palate fitted [by Robert Nasmyth]."
While her voice had become somewhat indistinct for some time after the operation, it subsequently completely recovered.
This contemporary description of the operation to remove the tumour provides the only clues as to its nature; it strongly suggests that it was probably either benign or of only a very low grade malignancy being locally invasive of the bone in the region subjacent to it; Liston was of the view that this was a benign tumour.(21) As to its exact histopathological origin, this is clearly impossible to establish with any degree of certainty. It appears to have originated from a trauma-induced mass in the region of the left cheek that gradually increased in size over a period of years and, curiously, appeared to be sensitive to hormonal stimulation. No mention was made of invasion of the local cervical lymph nodes, and the information provided by Liston suggests that, after its successful removal, the patient made a complete recovery. No indication is given of the weight of this tumour, but from its appearance it must have been considerable, as the contemporary drawings and the life mask show that the tumour was almost the same size as her head.
According to Liston:(22)
" ... a plate fitted by my friend Mr Nasmyth, of Edinburgh, with a portion attached to fill up the space (not very large) in the cheek. Besides removing the deformity, the patient is thus enabled to swallow comfortably and articulate distinctly.
During the cure, and until the edges of the opening in the palate have cicatrized, and until the aperture has contracted so far as it is inclined to do, the patient is rendered more comfortable by wearing a little paste made of crumb of bread well kneaded, this prevents foreign matters lodging in the wound, improves speech, and forms no bad dressing, a poultice in fact to the part."
If this poultice was changed relatively infrequently, it is possible that the mouldy bread might also have had a mild bactericidal action on the wound site.
ACKNOWLEDGEMENTS: We are extremely grateful to Dr Joe Rock for photographing the various life casts of the head of Mrs Fraser illustrated in this paper, and the Royal College of Surgeons of Edinburgh for permission to publish Figure 1. Mr Royds thanks the Faculty of Medicine for a Faculty Vacation Bursary.