ART. XVIII.-Contributions to Operative Surgery. Part I.:— Operations about the Face. By MAURICE HENRY COLLIS, M.B., Univ. Dub.; F.R.C.S.I., Surgeon to the Meath Hospital and County Dublin Infirmary; Member of Council of the Surgical Society of Ireland, and of the Pathological Society of Dublin; Sometime Examiner in Surgery to the Queen's University in Ireland, and Member of Council of the Royal College of Surgeons in Ireland, &c.

(Continued from p. 24).

REMOVAL OF AN ENORMOUS OSSIFIED-ENCHONDROMA FROM

THE FACE.

To the records of operations which have for their object the complete removal of the superior maxillary bone, I should hesitate to make additions. In the pages of this Journal and elsewhere enough has probably been written on the subject for some time to come. I have less hesitation, however, in presenting to the profession a detailed account of an operation which has another interest, inasmuch as it differs from those to which I have alluded in being of a more conservative character. As will be seen, I was able in this instance not only to preserve the palate, nostril, and floor of the orbit intact, and so to lessen to the utmost the deformities and inconveniences which would otherwise have resulted, but I further was able to preserve the periosteum of the bone throughout, and along with the periosteum, the attachments of the muscles. Hence, in addition to the preservation of intelligible speech, the muscular movements of the face, so essential to expression, have been preserved. This application of sub-periosteal resection is but a further extension of those principles which many years ago were put in practice by the writer in operations upon the hard palate-principles which the profession owes first to Mason Warren, of Boston, and in their present enlarged application to Langenbeck, of Berlin. The former, whose lead I had unconsciously followed, merely proposed to himself to make use of the periosteum, combined with its mucous covering, for ordinary plastic purposes; while to the German surgeon is due the higher praise of perceiving that the firmness, which this method of operating gave to the new palate, was due to some deposits of bone springing from the periosteum. Hence, he quickly applied this method to other parts, with a view of obtaining VOL. XLIII., NO. 86, N. s.

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a regeneration of bone from the retained periosteum, and with the greatest success. In resections of joints in operations on shafts of bone, and generally in all cases demanding the removal of bone for disease, this sub-periosteal method is now followed by all truly conservative surgeons. It must, however, be remembered that it has the further advantage, above noted, of preserving, along with the periosteum, much of the attachments of the muscles which spring from, and are continuous with this membrane. A moment's reflection will show the wide utility of the proceeding, viewed from this point, and how important its application, whether in operations which interfere with muscles of power, as in the limbs, or with those more delicate, but scarcely less important muscles of expression, which have their attachments to the surface of the facial bones. With these prefatory observations I shall proceed to the details of my case of sub-periosteal resection of the greater part of the superior maxilla.

Early in the present year I was consulted by a gentleman, well known in this city, with reference to a tumour, which produced much deformity of the left side of his face. This gentleman is somewhat under fifty years of age; is of active habits, and has always enjoyed excellent general health. The history which he gave me of the gradual development of his tumour was to the following effect:

"The first indication of the tumour on my face was a slight hard swelling on the gum just by my front teeth [left incisors], which I noticed when I was probably twelve or fourteen years of age. Since that period the swelling continued to grow steadily, but almost imperceptibly, until within the last three or four years, when it developed itself with singular rapidity, and attained such formidable proportions that I became anxious for its removal.

"Ever since the first appearance of the tumour it was carefully watched by Mr. Adams, and frequently examined (at his request) by almost every eminent surgeon in Dublin, including the late Sir Philip Crampton, Mr. Carmichael, Mr. Cusack, Mr. Colles, Mr. Maclean, the eminent dentist, and others.

"The general opinion at that period seemed to be against an operation, on the ground that there was nothing malignant in the growth; that it never would be otherwise than harmless, and because some, including Mr. Cusack, thought ten or twelve years since that it had ceased to grow. However that may be, the fact is

now undeniable that within the last ten or twelve years it has increased more than in all the previous period.

"Some years before Sir Philip Crampton's death, Mr. Adams, Mr. J. Smyly, and I were with him in Merrion Square, and he then made a puncture from the inside of the nostril into the interior of the tumour, and inserting a small tube, got out a trifling quantity of fluid, not more than a drop or two. He first endeavoured to bore through the gum, but failed, apparently from the solidity of the bone. About the same time Mr. Maclean extracted a tooth near the front [left canine], and then made some ineffectual examination with a probe, or some such instrument. I did not feel the extraction of this tooth. I may add I was always deficient by a tooth on this side. The sight of my left eye left me very gradually. It evidently went as the tumour extended, and about fifteen years ago it became completely extinct."

Such is the simple history of this growth, as written down at my request by the gentleman. I have only to add to it a very few particulars, elicited on conversing with him. In the first place the tumour from the very outset was always firm and hard to the touch, showing that, at least, its covering was bony; further, there was no pain either in the tumour itself or resulting from its pressure during the greater part of its progress; even the loss of the eye was so gradual as to be painless, any sensation amounting only to uneasiness. Within the last two years the tumour has grown rapidly forwards, and has distended the soft parts of the cheek. Browache, with shooting pains of a dull nature, have been felt rather constantly during that period. Hearing on that side has also become somewhat dull. The pressure on the left nasal cavity has made it quite impervious. Breathing is impossible through the left nostril, nor can air be forced through it to any appreciable amount. The sense of smell is necessarily in abeyance as regards this side. Even the other nostril participates in the inconvenience, so that when the gentleman is in a warm, dry atmosphere, his comfort is much impaired by reason of a dryness and stuffiness in the nasal passages, and the immediate occurrence of ache in the frontal sinus. With these exceptions he has no physical inconvenience from the tumour, nor until lately did his moral courage fail to support him in bearing, with equanimity, the deformity with which he was afflicted. Cotemporaneous, however, with the rapid increase of the growth and its commencing pressure in new and important directions, came

sensibility to observation; and although he continued to go about the city as freely as ever on matters of business, he assured me, and his assertion was corroborated by the observation of his near friends, that the effort was painful, and that, as far as possible, he had withdrawn from positions of prominence which formerly afforded him pleasure. This is an interesting psychical phenomenon—for it must be remembered, that as far as the public are concerned, the impression produced by the size of the tumour has been at all times much the same. The sensibility to the increase of the tumour was practically limited to the patient himself, to the immediate members of his family, and to those professional friends who had him under observation. And yet, along with a development of the tumour, which, as we shall see, threatened life, there arose in the patient's mind, all unconscious of his danger, first a dislike to be observed, and as that increased, a desire and determination to get rid of the deformity. This acquiescence in the necessity for operative interference, or its opposite condition, a repugnance to the same, may be taken, in reasonable people, as a valuable aid to the surgeon where the propriety of operation is wrapped in more than usual doubt. Without laying too much stress upon it, I would certainly give it in such cases, due consideration. In the present instance the feeling was strong that the time had come when, at all hazards, the tumour must be removed.

I shall now show, by a description of the growth and its relations to surrounding parts, how well founded was this feeling, and how just these apprehensions.

Placing the patient almost in profile, and looking at him from the right side, as in the position shown in Plate I., it was observed that the tumour projected in an even curve from the floor of the orbit to the mouth, so that the prominence of the tumour extended a full inch beyond the outline of the nose. The two nostrils looked directly towards the observer, so great was the distortion of the nose. The left nostril was somewhat dilated. The outlines of the mouth were much altered, owing to the left side of the mouth being depressed, and the left side of the upper lip was much distended over the lower part of the tumour. The lower lip and upper part of the chin were thrown deeply into shadow, and also somewhat out of drawing. Upon reversing the position, as in No. 2, the great prominence of the tumour came fully into view. It occupied the whole region of the cheek, and bore upon its surface evidence of two distinct epochs of growth. If a line be drawn from the

inner angle of the left eye to the angle of the lower jaw on the same side, two distinct types of growth will be noticed, the one occupying the face above, and to the outer side; the other below and internally. I shall take the former first, as it represents what, for want of a better term, I may call the more chronic condition of the tumour. We observe here a distinct elevation of the floor-line of the orbit; this is not due merely to an elevation or pushing up of the lower eyelid or other soft parts; the finger and even the eye could detect that the bony ridge itself was higher than that on the right; otherwise the bone in this spot was not altered in texture or outline-it was simply pushed upwards. On the outer side the junction of the maxillary and malar bones is prominently seen; the bones here were expanded, but the body of the malar was not altered in size-it was plain, therefore, that the disease was limited in that direction. Altogether, then, it appeared evident that there was no present active extension of the growth above or outside the line I have imagined to be drawn from the inner angle of the eye to the angle of the jaw. Within this line matters were far different. Reaching high up on the nose, almost to the angle of the eye, and to the central line, a rounded mass of bony hardness, was formed. On the inner side it passed down as far as the lower margin of the ala nasi, where it was joined by a second mass which reached far down into the mouth, and which bore upon its buccal extremity two incisor teeth. Passing outwards these two portions, separated by a fissure on their nasal aspect, became consolidated together, and formed by their union a mass of great size, still rounded in outline, and of firm inelastic nature. The growth pushed the nose out of the mesial line to an extreme degree, and extended outwards and forwards, so as to distend the soft coverings of the cheek to a huge extent. On opening the mouth it was found to have extended backwards to the palate bone, and to have pushed down the palate process of the maxillary even to a greater degree than it had pushed up the floor of the orbit. Along the alveolar ridge it had grown to a greater degree than at any other part, except towards the nose. It was evident that its progress in these directions was fast reaching the utmost limits compatible with any approach to comfort, and that a little more increase would soon threaten existence. This extension downwards, and threatened extension backwards, was likely to lead sooner or later to the filling up of the cavity of the mouth. In Hey's works will be found the drawing of such a case, where the tumour developed in this direction to an enormous amount.