Compliments of J. S. Bnist, M. D. 
[From the Medical Transactions, 1874.] 
Excision of Superior Maxillary Bone for 
Fibro-Sareomatous Tumor, (“Epulis”) 
in a Child nine years of age—‘Cure. 
BY J. S. BUIST, M. 1>. „ 
S. CL 
CHARLESTON, S. C.: 
Edward perry, printer and stationer, 149 meeting street, 
1874. [PAPER D.] 
Excision of Superior Maxillary Bone for Fibro-Sarcomatous Tu- 
mor, (“Epulis”) in a child nine years of age—Cure—By J. S. 
Buist, M. I)., Charleston, S. C. 
The report of the following case, as illustrated by the accom- 
panying designs, and the pathological specimen, herewith shown, 
is of sufficient importance, and presents points of interest, not from 
any peculiarity of the growth or new developments in changes of 
tissue, by morbid action, but as illustrating—1st. The rapidity of 
growth in tumors of this class. 2nd. The quickness with which 
recovery occurred, upon the removal of the mass, interferring as 
much as it did with the proper nourishing of the body. And 3rd. 
The extreme youth of the subject upon whom such a grave opera- 
tion was practiced. 
I was called to see Abram, a colored boy, aged nine years, on 
the 20th day of April, 1871, with the view of suggesting relief to 
a rising, so-called, upon the face, and found, as expected, a large 
tumor of the upper jaw, left side. The following "history was ob- 
tained : About nine months previous to observation, the first evi- 
dence of disease commenced to exhibit itself, by the presence of a 
small rising or hardened nodule upon the mucous membrane of 
the roof of the mouth. This gradually increased, extending up- 
wards, backwards and forwards, until the tumor commenced to 
show itself anteriorly, by producing an elevation of the upper lip, and 
protrusion of the growth externally, occupying the whole of the 
left side and half the front of the face. Upon examination, the 
following was found: A large, tense, unyielding mass, occupying 
the whole of the left side of the face, extending slightly forward, 
filling the cavity of the mouth, and extending backwards, bounded 
by a well defined and free margin, separate and distinct from the 
hard palate. The tongue was pressed out of position and lay 
against the right cheek. The impress of the teeth upon the free 
margin of the tumor was present, and at a few points, they were 
imbedded by ulceration into its substance, giving rise to offensive 
and ugly discharges, with occasional hemorrhage. Articulation 
was impaired to a great degree. The skin was moveable and loose. 
Constant salivary discharge was present, rendering with the defor- 
mity the subject one of commiseration. In appearance the tumor 
was of a pinkish white color. The general health was good. 
Power to masticate upon the sound side had been entirely lost. 
Nourishment consisted of soups, milk, &c. &c. 
The nature of the growth, its rapidly extending tendency, its 
non-malignant character, and above all, the effects upon the con- Showing the appearance of patient before operation of Excision 
oj Maxillary Bone for Fibro-Sarcomatous Tumor. 
By J. S. Buist, M. D., Charleston, S. C. 
Figure No. 1. 3 
stitution of the child, together with the extreme gravity of the 
operation, and the tender years of the hoy, being all taken into com 
sideration, operative procedure was determined upon, after con- 
sultation and a review of all the facts in the case. Some slight 
preliminary treatment having been instituted, on the morning of May 
8th, with the assistance of several of my professional brethren, I 
practised the following modification of Dieffenbach’s operation : 
the patient being placed in a semi-recumbeut position, head and 
shoulders elevated, was as rapidly as possible brought under the 
influence of chloroform. The three upper incisors were drawn. 
A vertical incision near the median line and nearly midway be- 
tween the canthi of the eyes was then made, extending a little to 
the left and through the nose and lip, the knife penetrating the 
left nares, close to the septum. The single flap thus made was 
carefully dissected up, when it was found that ample room was 
obtained to expose the whole upper surface of the tumor. A 
transverse incision about half an inch in length was next made 
from the upper angle of the first incision towards the left eye, thus 
exposing the upper attachment of the bone. Section of the malar 
attachment of the bone was then made with a strong pliers. The 
hard palate and nasal process were then divided in the usual 
way, with Liston’s pliers. The tumor being then seized and 
strongly pressed downwards with a few touches of the knife and 
scissors, all of its attachments were divided, and it was removed. 
Little or no hemorrhage followed. Two small arterial branches 
were severed during the operation, viz. : the angular, severed in 
the first incision, and one of the small branches of the palatine, the 
larger vessels being obliterated by the effects of the pressure of the 
tumor. The wound having been sponged out with a saturated solu- 
tion of alum, to quell any oozing, was brought together by five points 
of interrupted silver wire suture, the cavity being supported by 
pledgets of lint, wet with carbolic acid and glycerine, and a band- 
age applied over the parts to keep and support them. Small doses 
of morphine were given at intervals to control pain, and the utmost 
quiet enjoined. The patient reacted promptly, small doses of stim- 
ulant being administered occasionally At the end of the third day, 
suppurative symptoms developing themselves, the pledgets of lint 
were withdrawn, the cavity sponged and injected with a weak 
solution of carbolic acid and water, the dressing being removed 
and renewed each morning thereafter. The bottom of the cavity 
was healthy, the pus laudable, with considerable swelling about the 
palatine arches and pharynx, though not sufficient to interfere with 
deglutition, nourishment consisting of milk, soups, &c., &c., being 
administered through a tube. On the morning of the fifth day, 
the entire lines of the incisions having apparently united, three oJ 
the sutures were removed and small strips of ichthyocoll plaster sub- 
stituted. On the seventh day the other two sutures were removed, 
the wound having united by first intention, through its entirety The cavity of the mouth rapidly filling up, the strength of the 
patient gaining from day to day, the usual treatment as adopted in 
such cases being continued, at the end of three weeks the boy re- 
turned to his home completely cured and presenting, as will be 
seen by the second figure, a much handsomer face than the owner 
was entitled to, notwithstanding the keen blade of the knife and 
crushing effects of the lion forceps. At this time no evidences of 
a return of the tumor are present. The child has grown, is ro- 
bust and hearty, masticates any kind of food upon the sound side, 
and unless upon a close examination, the cicatrices cannot be ob- 
served and deformity is absent. 
The tumor, as will be seen, embraces the whole of the left 
maxillary bone belongs to the class described by pathologists as 
epulis. Beginning, as it always does, in a thickening of the 
mucous membrane as an elevated nodule upon the gums, it rapidly 
increases in size and embraces the whole of the bony structure, in 
the connective tissue elements of which it primarily takes its origin, 
having its matrix or point of start in one of the sockets of the 
teeth. It is always dense and firm of consistence, of a florid color, 
and peculiar fibrous structure. Its progress is rapid, and painful; 
and being nearly always located about the mouth and face, fills the 
cavity and interferes with mastication, articulation, and sometimes 
even with deglutition and respiration. This form of tumor is 
liable to come on at any time of life, and in both sexes. Of its 
exact pathological character, scientists are divided in opinion, and 
where to place it, has not yet been determined. Most writers 
seem to regard it as belonging to the sarcomatous variety of dis- 
ease, and it certainly approaches these affections more nearly, in its 
progress, symptoms and reproductive tendencies, than any we are 
acquainted with. Of the exciting causes, nothing is known. Hav- 
ing a tendency to recur in many cases, the constitution seems to be 
affected. Certain it is, that the only remedy is early and thorough 
excision, not of the tumor only, but of the entire bone or part of 
the bone that may be affected, and where, as in the case that has 
just been described, the whole maxillary bone has become diseased, 
the only alternative is complete and entire extirpation, even though 
the risk of death from the procedure be-imminent. 
Excision of the upper jaw was practiced by Acoluthus as early 
as 1693, but the honor of first extirpating it in whole, is due to 
the late Dr. Jameson, of Baltimore, who achieved the enterprise 
successfully in 1820. In the large majority of cases described by 
authors, the subjects have been adults, of strong, vigorous consti- 
tutions, and even then the mortality has been very large. In search- 
ing the records, but few instances can be found, where those of ten- 
der years have been operated upon successfully, and as the case 
described is one of this character, it is thought best to place it 
upon record as one of the evidences of the efficiency of our art to 
relieve human suffering. Figure No. 2. 
Showing the appearance of patient after operation of Excision 
of Maxillary Bone for Fihro-Sarcomatous Tumor. 
By J. S. Buist, M. Dt> Charleston, S. C.