Ji Modified Operation in Excision of the Os Maxillare Superius.
By W. E. Horner, M. D., Professor of Anatomy in the Uni-
versity of Pennsylvania, and Senior Surgeon in the St. Joseph’s
Hospital.
This once formidable operation, has latterly been so often per-
formed successfully, that but little of novelty, or of special interest,
is now attached to it. Its feasibility thus established, a mitigated
form of its execution may, however, be a sufficient excuse for the
present brief allusion to a case of the kind.
The following letter from the patient himself, exhibits the early
condition and progress of his affection. He is now aged eighteen.
Dr. Horner: Dear Sir,—In August, 1847, I suffered for four or five days
from a severe headache, sickness of stomach, and a general uncomfortable
feeling, which was followed by a purulent discharge from a small orifice in
the left side of the roof of the mouth. After a few days, two or three
pieces of a hard substance sloughed out, leaving an opening the size of a
pea-nut. Soon after this, the discharge ceased, and the opening gradu-
ally healed up. At this time there was a flat tumour occupying nearly the
whole roof of the mouth on that side. This swelling increased slowly, and
extended so as to involve the alveolar portion of the maxillary bone, and
cause a loosening of the back teeth. About the middle of last May, the
middle molar tooth was extracted, without, however, causing any material
difference in the size or appearance of the tumour; which, during the few
months previous to its removal, increased, I think, somewhat more rapidly
than in its earlier stages. From the time of the first appearance of the
tumour, to its removal, I am not conscious of having suffered any pain from it.
Yours respectfully,	M. W. A.
In consultation with Drs. J. M. Allen, the uncle of the pa-
tient, George W. Norris, ancl Henry H. Smith, a decision was
had for the removal of the diseased bone along with the tumour.
During the deliberations on the case, which lasted two or three
weeks, the tumour bad grown somewhat, but was not painful; its
size, however, was inconvenient in eating and talking, and affected
the motions of the tongue. There had been no discharge from the
nose, which led us to hope that the tumour had not reached the
antrum highmorianum.
The operation occurred on the 28th day of October, with the assist-
ance of the surgeons above named, and some young gentlemen, stu-
dents of medicine. The tumour, at this date, occupied the whole
of the left side of the hard palate, and made a volume of about
half the size of the largest hen egg. All the teeth of the left upper
jaw were loose, the posterior ones rising from their sockets, and
the anterior vibrating sensibly. It was thus plain that the gums
and alveoli were all affected by the extension of the disease.
I had previously determined to avoid, if possible, the through
incision of the cheek as commonly practised, owing to the perma-
nent deformity left by it. The following proceeding was therefore
had. The patient, seated in a chair, was placed under the influ-
ence of ether, by inhalation. The mouth being then held open,
the upper lip and the cheek were raised from the maxilla superior,
by an interior incision in a line parallel with the superior margin
of the buccinator. This part of the operation was preceded by
the extraction of the two left incisor teeth. The corresponding
alveoli were then removed. The first step of the latter was
to cut in front, with a narrow saw, along the middle palate
suture from the mouth into the left nostril, until the palate
plate was reached; then, with a pair of strong hawk-bill scis-
sors, such as are used by gardeners for lopping off twigs, an
incision was made so as to take out at a clip the whole of the
two vacated alveoli, in other words, what is considered by some
as the intermaxillary bone of the human subject. A thin, flat
knife, well tempered, and with a strong round handle, was then
passed from the mouth into the nose, at the posterior part of the
middle palate suture, and this suture cleaved in its length from the
soft palate to the nick left by the excision of the intermaxillary
bone. The narrow saw was again used to cut through the root of
the nasal process of the maxillare superius. A pair of strong scis-
sors, curved on the flat, was then taken, to clip through the exterior
and the interior side of the maxillare superius, a little below the
orbitar plate; the incision being carried back to the pterygoid
process of the sphenoid bone. The base of the soft palate was
then detached by a short triangular knife, curved on the flat.
The greater part of the upper maxilla being thus loosened all
around, and insulated, it was brought away with the tumour all in
a body, after cutting through a few shreds of attachment to the
back of the cheek. The pterygoid process—the os malse, and the
orbitar plate of the maxillare superius, were not disturbed, but left.
The tumour, contrary to our hopes, also occupied the antrum, so
as to be as large above as it was in the mouth ; it was also
attached to the posterior part of the cheek, and to the external
pterygoid muscle. A careful removal of it with gouge and scis-
sors, was accomplished wherever any part of it could be detected.
The bleeding was profuse, especially from what was considered
to be the posterior palatine artery ; it was secured with the aid
of Physick’s forceps and needle ; some few other arteries were also
secured by ligature. The parts being well washed, were then
carefully packed with successive small pellets of coarse charpie,
firmly pressed in, and the base of the packing was supported by a
thin board of a semicrescentic shape, somewhat larger than a half
of the hard palate. This board was sustained by the teeth of the
lower jaw, the latter being fixed by a bandage as in fracture.
The bleeding in this case was so profuse during the operation,
that the latter was suspended at intervals, so as to clear the throat
from the accumulation of blood, which embarrassed respiration.
The dressing was so effectual, that we had no trouble with the
bleeding afterwards. By the 9th day of November, i. e. in twelve
days, the patient was in a fine state ; the lint and the ligatures had
all come away. In a few days afterwards, the patient began to
exercise out of doors, and by the last of the month, I had the plea-
sure of seeing him apparently perfectly well, with not the slightest
external indication of the operation, and with a face so straight
that his nearest acquaintance would not, of himself, have suspected
any thing, and least of all, that almost the whole of the upper
maxillary bone had been excised.
The board is liable to displacement; J should, therefore, under
similar circumstances again have a spring, or some arrangement
to fix it permanently and securely.
The additional time required for this mode of operating, is pro-
bably fifteen or twenty minutes; but as a scar in the face is an
affair for life to the patient, it should, if possible, be avoided,
which, if it cannot be accomplished in all, may certainly be in
many cases.