THE DUBLIN QUARTERLY JOURNAL OF MEDICAL SCIENCE. MAY 1, 1867. PART I. ORIGINAL COMMUNICATIONS. ART. XII.-Surgical Reports. By GEORGE H. PORTER, M.D., Univ. Dub.; F.R.C.S.I., Senior Surgeon to the Meath Hospital and County of Dublin Infirmary; Surgeon to Simpson's Hospital; Examiner in Surgery Royal College of Surgeons, Ireland; Consulting Surgeon to the Coombe Lying-in Hospital; Member of Council of the Surgical Society of Ireland, and of the Pathological Society of Dublin; Lecturer on Clinical Surgery. I.-EXCISION OF A LARGE PORTION OF THE UPPER-JAW FOR EPULOID DISEASE; RECOVERY. II. COMPLETE EXCISION OF THE ELBOW-JOINT FOR STRUMOUS DISEASE; RECOVERY. III.-EXCISION OF A LARGE-SIZED EPULIS SPRINGING FROM THE LOWER-JAW; RECOVERY. 1.-Excision of a Large Portion of the Upper-Jaw for Epuloid Disease; Recovery. In every operation in any degree implicating the human face it must ever be desirable, as much as possible, to guard against the VOL. XLIII., No. 86, n. s. 8 production of subsequent deformity. The removal of an unsightly tumour of the jaw-bone, which distorted the soft parts of the face covering the swelling, is a great benefit; but in accomplishing this the prevention of disfigurement, by cicatrices of those structures, is of the utmost importance. Among those eminent men who, by their valuable suggestions, have aided the operator in excising the upper jaw, or portions of it, Sir William Fergusson holds a foremost position. Various incisions to lay bare growths from the superior maxilla have been recommended, all of them most useful in the cases to which they are immediately applicable, and tending to assist the surgeon in dealing with such tumours. I believe, however, that in the majority of instances, a small amount of cutting into the soft parts will suffice to allow the excision of a large portion of the upper-jaw. The following case, I consider, proves, in a very marked way, the advantages of the simple incision practised by the distinguished surgeon before mentioned in removing tumours of a moderate, and even of a large size from the upper-jaw. The trifling incision made vertically through the centre of the upper-lip, and prolonged into one or both nostrils, affords space enough to remove most of ordinary tumours of the superior maxilla, and leaves very little trace, or slight disfigurement behind. Great stress is laid upon the advantages of this incision by Sir William Fergusson, in the following quotation, which I take from one of his lectures (No. IV.), delivered at the Royal College of Surgeons, London, in 1865, on the "Progress of Surgery during the present Century." He says:"There are two advantages of great importance, in my opinion, associated with this incision. First, the wound being made in the furrow below the columna, and exactly in the middle of the lip, is less observable than on any other part; and next, there is an inch in length gained by the natural opening of the nostril. The ala of the nose is so easily raised, and with the tip can be so easily moved according to the will and wish of the operator, and the cheek can be so readily dissected off the tumour as high as the margin of the orbit, and as far out as the malar bone, that a large space for operation on the anterior surface of the maxilla is easily made. Since 1848 I have never made any other incision in the upper-lip; and I have no hesitation in stating, from experience of twenty cases or more, that in a number of operations of moderate-sized tumours there is no need for more extensive incisions on the outer surface of the face." Bessy G., aged forty years, married, was sent to me by my friend Dr. L'Estrange, of Dublin, and admitted into the Meath Hospital, August 10th, 1867. Her health appeared to be good; she was not wasted, nor did she complain of pain. Her left cheek was visibly swollen and distorted, and a well-defined tumour, of a somewhat globular shape, appeared about its centre, but still the deformity was not very great, She stated that the growth was of nearly three years' duration, but latterly had commenced to increase very rapidly. On opening the mouth a tumour about the size of a hen's egg came into view. Its surface was smooth, with the exception of a speck of ulceration, about the size of a three-penny piece, in the centre of its most prominent point. It was almost globular, but slightly longer from before backwards. The two incisor, and the last molar teeth were all that remained on that side of the upperjaw. The colour of the tumour was a little deeper than that of the healthy gum structure. To the touch it was very firm, but not of a stony hardness, nor was it nodulated. It had never bled. It extended half way in on the roof of the mouth. The patient found some difficulty in masticating, and her voice was a little interfered with. The left nostril was quite free, and there was no glandular enlargement to be found anywhere. As there was no evidence whatever of malignancy, and having had the advice of my colleagues, I determined to excise the growth. To this she at once assented, as she had come into the hospital for that purpose. Operation, August 22nd.-I excised the tumour in the following manner: She was placed sitting in a strong chair, which was then gently thrown backward, so as to put her in a semi-reclining position, whilst chloroform was carefully administered. This having been accomplished, Dr. L'Estrange extracted the two left incisor teeth in a most expert manner. My assistants then raised the chair, so as to bring her again to an almost erect sitting posture, the head slightly drawn backwards, and held firmly. I then, with a medium-sized scalpel, quickly cut through the upper lip, exactly in the median line, and immediately afterwards carried the incision into the left nostril. A colleague then seized the opposite flap, whilst I held the one on the diseased side, so that bleeding from the coronary arteries was arrested. This amount of cutting, combined with traction made on the cheek by means of a copper retractor, brought a great portion of the abnormal growth into view. Keeping the knife close to the bone, I cleared the soft structures from the maxilla fairly above, and isolated the tumour superiorly to about a quarter of an inch below the infra-orbital |
