Upon the Entire Resection of both Superior Maxillary Bones. By
M. IIeyfelder, Professor of Clinical Surgery at ErlangeD.—Gensoul
at Lyons, and Lizars in England, were the first to extirpate (1827) the
superior maxillary bone of one side in cases of disease. Since then the
operation has been often repeated, and in 1846, Ried [Die Resectionem
der Knochen) was able to collect thirty-five cases, of which twenty-four
were followed by success. If to these be added the cases of Morel-La-
valle, Maisonneuve, Chaissaignac, Robert, and Muston, together with
those related in the Surgical Cliniques of Munich, Wurzburg, and Er-
langen, not yet published, above fifty cases may be easily enumerated.
The same remark cannot be made of the resection of both superior max-
illae. M. Velpeau accords (he honor to Rogers, “ who, in 1824, took
away the upper jawbone of both sides as far as the pterygoid processes,
and who found it scarcely necessary to divide the lip.” This descrip-
tion is too brief to be intelligible. Liston removed the entire superior
maxillae of one side, and part of the other. Dupuytren (1818) effected
the partial removal of both maxillae in a man sixty-eight years of age.
Th us, the cases hitherto known are but examples of the partial resec-
tion of both maxillary bones.
The complete extirpation of both bones has been performed by Hey-
felder twice. The first operation was in the summer of 1844; the
second, in January, 1850.
Case 1.—A. Schmidt, aged 25, came to the Clinique, June 13th,
1844, suffering from a tumor of the face, which, from his account, had
commenced a-year ago, in the posterior part of the palate, and had gra-
dually involved both superior maxillary bones. The nose was pushed
upwards, and flattened; the palatine arch was depressed towards the
tongue; the face was affected with (Edematous swelling; both respira-
tion and deglutition were impaired, speech was embarrassed, and the
sleep broken. The teeth, though loosened, were sound; only two inci-
sors were wanting. The tumor appeared everywhere hard, uneven, and
insensible to the touch, and did not pass beyond the boundaries of the
superior maxillary bones. The constitution was good; lancinating pains
had been felt in the tumor only during the last few weeks.
Dr. Heyfelder concluded that the tumor was of an indolent malignant
character, and that the only remedy consisted in the entire removal of
both maxillary bones. The operation was performed, June 23, 1844.
The patient being seated in a chair, the head resting against the chest of
an assistant, two incisions were made from the external angles of the
eyes in the labial commissures, and the included parts were reflected up-
wards to the internal angles of the eyes, and to the ossa nasi. The flap,
thus formed, was raised towards the forehead, until the infra-orbital
ridge was exposed. Then the chain-saw of Jeffray was passed through
the splieno-maxillary fissures, and the molar bones were divided; the
maxillse were next separated from the ossa nasi; the vomer and the thin-
ner bones were cut with strong scissors; after which a chisel, applied
with moderate force to the superior part of the tumor, was sufficient to
effect its separation. The accessions of syncope prolonged the operation,
which, however, did not last longer than three quarters of an hour. Very
little blood was lost; torsion and compression sufficed to arrest the
haemorrhage. Two hours afterwards, the edges of the wounds, from the
angles of the eyes to the corners of the mouth, were united by twenty-
six points of suture, and cold lotions were applied ; there was no re-
action nor swelling; the patient could swallow water and broth. Four
days after the operation it was remarked, that the wounds had become
almost entirely united by first intention. In six weeks the patient was
presented at the Physico-Medical Society of Erlangen, and on August
25 he was discharged.
The following was his condition :—There was no deformity of the
features : in his mouth there was seen along the median line a fissure
thirteen lines long and three lines broad ; the extirpated parts had been
replaced by the tissue of a cicatrix, firm and solid at the circumference,
but somewhat softer near the fissure; the soft palate and the uvula were
in their natural place; deglutition was free, and the tongue in a better
state than formerly; the nose had resumed its usual form and direction ;
the face, which, before the operation, was monkey-Jike, once again pos-
sessed a human expression.
The microscopical examination of the tumor showed that it was of
cancerous nature. Six months afterwards, the patient, in good health,
went to work in the fields; but in the summer of 1845, Dr. Heyfelder
was informed that another tumor was forming in the forehead.
Case 1.—Martin Lochner, aged 55, was affected in the upper lip,
twelve years ago, with a cancerous growth, which was operated upon
three years after its appearance. For two years there was no return ;
but, subsequently, a small tumor developed itself near the cicatrix, ap-
proached the nose, and excited violent pains. Soon a cancerous ulcer
formed, which extended over the right half of the upper lip, the ala nasi,
and the palate. The patient came into the hospital Jan. 21, 1850, in
the following state :—A horrible cancerous ulcer, commencing at the
right commissure of the mouth, occupies the greater part of the upper lip,
and has destroyed both the right ala and the septum nasi. All the parts
were covered with painful, bleeding, fungous growths. The palatine
arch was converted into an irregular, knobbed, cancerous mass; mjost of
the teeth were lost; an offensive secretion was constantly flowing, and
the patient was thinned and worn out.
The operation was performed January 24. Two incisions were made,
exactly as in the preceding case. The chain-saw was used to separate
the left os malse, and Liston’s bone forceps to divide the right. The re-
mains of the septum nasi and the vomer were cut with strong scissors.
A considerable quantity of the soft parts was likewise taken away. The
patient was fed by a syringe. The left coronary artery bled three hours
after the operation, but it was easily tied. The case went on well; and,
on February 18, when the patient was presented at the Physico-Medical
Society, the following was his condition :—The greater part of the wounds
were united ; but a deficiency existed in the face, corresponding to the
disease, at the superior part of which were seen the vertical portion of
the ethmoid, and the two ethmo-turbinal bones. In the velum palati
there was an opening, two centimetres wide. The destruction of the lip
and of the nose produced on the right side a triangular opening, the base
of which corresponded to the mouth, and the superior angle to the root
of the nose.
He can take liquid food, but his speech is unintelligible; but, when
the opening in the palate is closed by the sponge, he can make himself
understood. Autoplastic operations were unadvisable, from the ex-
hausted condition of the man.—Med. Times & Gaz. from Rev.Medico-
Chirurgicale de Paris.