Operating Conditions

If we could step back in time to 1830, perhaps the first difference that would be apparent would be the surgeon’s dress. At that time it was usual to wear an old frock coat that hung on the back of the theater door: the more encrusted with blood and pus the more honorable it was. Surgical gowns and gloves belong to this century: even after the introduction of asepsis by Lister in 1867 it was usual for surgeons to operate with bare hands until at least 1895.9

Resection of the upper jaw was classified as a “capital operation,” so called because the patient could, and often did, die during or immediately after the operation. It was usual to give notice, not only to the medical profession but also to society in general, of forthcoming operations of this type. Thus the audience included not only medical students but curious bystanders: the famous violinist Paganini performed a tour of England and Scotland in 1831–32, and attended a maxillectomy performed by Earle in 1831. At the end of the operation, Earle came forward and was greeted by “deserved applause.” This operation had to be postponed because the rumor of it had brought together such a multitude that even after an adjournment to the anatomy theater, it was impracticable to continue with the operation.10 The operation performed by Liston in 1835 attracted several hundred spectators. The operating theater was so called because the seats were arranged in ascending rows, as in an ordinary theater, for easier viewing. For similar reasons, it was called an amphitheater in France (Fig. 2.3).

Pathology

The second enormous difference between the present day and the 50-year period from 1820 to 1870 during which maxillectomy was developed, was in pathological diagnosis. Surgeons had no histopathological description of the tumor on which to base their classification until ca. 1855, and the terms used were merely descriptions of the macroscopic appearance of the tumor. Histopathology was not placed on a firm basis until the publication of Virchow’s book in 1856. He was the first to describe tumors on the basis of their cellular appearance.8 Gross descriptive terms were still being used as late as 1863 when Barton stated that maxillary tumors may be divided into medullary, scirrhous, melanoid, or epithelial.11 Furthermore, even after histopathology became generally available around 1860, histological examination was restricted to postoperative examination.12 The examination of a biopsy belongs to this century: indeed, as late as 1923 Ochsner was vigorously maintaining that preoperative biopsy with a knife led to the setting up of metastases.13

A patient described by Dickson in 1840, though not subjected to operation, gives useful insight into the appreciation of gross pathology at that time. The patient was described as having a “fungus of the antrum with lymphatic contamination, but not visceral taint.” The lymphatic contamination was a lymph node enlarged to the size of an almond in the digastric space. It was clearly appreciated that this was a malignant tumor which had spread to the lymph nodes so that the tumor was therefore incurable. A necropsy was performed 12 hours after death showing no “visceral taint,” that is, no distant metastases.14

In 1833 there were three indications for resection of the upper jaw:15

• 
  

  “Malignant disease”

  
  
• 
  

  “Augmented growth of the bony parts”

  
  
• 
  

  “A sort of dropsy”

The terms used for “malignant disease” were often so vague that it is now impossible to know what they described. They included tumor, intumescence, malignant disease, medullary disease, sarcoma, and so on. The term carcinoma was not used in relation to the maxilla until 1878 by a German, Koerte.15 However, it is clear that the lesions were often carcinoma, and that the terms medullary tumor and sarcoma were squamous carcinomas. The word sarcoma was often used in its literal Greek meaning, that is a “fleshy tumor.” It did not take on the connotation of a tumor of mesodermal origin until the latter part of the 19th century. Virchow in his classic Cellular Pathology tells us that the term medullary disease arose from the idea that it originated in the nerves and resembled nervous matter. This tumor was originally thought to arise from the body of the sphenoid bone or other bones of the base of the cranium, but Heath showed that it did indeed originate in the maxillary antrum itself.16 A review of 160 maxillectomies published between 1830 and 188011,14,15,17–145 shows that ~50 of the 160 were done for carcinoma, although it was said that “cancer is certainly a very unusual form of growth to occur in the upper jaw.”71

“Augmented growth of the bony parts” may refer either to bony tumors or to fibrous dysplasia. Of the first 160 cases, 19 were described as being bony tumors of some sort, such as exostosis, and many are described as osteosarcoma. Of 14 patients described by Dieffenbach, 6 were classed as osteosarcoma.47 This description was not based on histology, and it is unlikely that almost half his patients suffered from so rare a disease. However, some of the bony tumors described were clearly osteomas; for example, the antral tumor described by Bickersteth in 1857, which could only be examined by sawing it in half.25 It is interesting to speculate why osteomas (or exostoses) appear to have been so common in the early part of the 19th century.

“A sort of dropsy” was almost certainly expansion of the antrum and erosion of its bony walls by an expanding retention cyst. A patient who had undergone resection of the entire upper jaw for a cyst via a Fergusson type of incision on the face was shown at a meeting of the Medical Society of London in 1874.70 The surgeon was strongly criticized for carrying out an operation that was more serious than the disease required. Another member pointed out that many of these cysts were of dentigerous origin, and were cured by the removal of the offending teeth, an opinion which would hold good to this day. Another dentigerous cyst of the antrum was described by Bryant, who said that doubtless upper jaws had been removed in former times for this affection, its true pathology not having been understood.146

Another common diagnosis not included in Guthrie’s classification15 was fibroid tumor or fibroplastic disease. Thirty of the first 160 maxillectomies were for such tumors. From detailed descriptions this tumor had a firm consistency with thin adherent bone, that had been eroded by pressure. Many of these tumors presented with a nonulcerated swelling of the palate; some later histological studies described fibrous tissue. Many of these tumors are clearly what would now be called angiofibromas, and a series of them is described by the Irish surgeon Butcher.31–34 However, not all these tumors were angiofibromas as they appear to have arisen in both sexes and at all ages. Microscopy of one of these fibrous tumors showed elongated cells forming fibers, calcareous matter deposited along the course of the fibers, and a central hard portion infiltrated by earthy salts converting it into a stony mass.90 This tumor was almost certainly an ossifying fibroma. A fibrous tumor, described as a fibrosarcoma, was removed from the upper jaw of a man of 58 by the well-known Irish surgeon Stokes in 1873.147 The histological appearances showed tough fibrous tissue with a few small blood vessels.

At least a dozen maxillectomies were performed for what was described as necrosis or caries of the upper jaw, due to syphilis,27,117 typhus,148 or occupational exposure to phosphorus.149

Microscopical examination of tissue removed surgically began in the 1850s: Brainard in 1852 in the United States was one of the earliest practitioners describing the tumor as presenting no trace of cancerous tissue and said that no cancer cells were detected under the microscope.150 This examination was not necessarily based on examination of a section, because Craven in 1863 comments “under the microscope the juice scraped from the cut surfaces exhibited no fibrous element but simply a confused mass of broken up cells and granular matter.”39 Thus, in the early stages it appears that some form of cytology was practiced on cells scraped from the tumor. Furthermore, examination of sections as we know it did not develop until the end of the 19th century. Until then specimens for histology were preserved in alcohol20 and cut by hand, but in ca. 1866 His made his sliding microtome, which was improved in the following decade. Automatic machines began with Threlfall’s, made in 1883. These demanded rigid embedding of the specimen in substances such as paraffin wax.7

Early histological reports include that by Clark in 1856, who described a tumor “under the microscope as presenting cells and nuclei of every size and shape. A few commencing characteristics of epithelial cancer were present sufficiently distinctly to show positively that the tumor belonged to that class.”36 Another tumor94 was encased in true bone, and histologically showed “oily globules compressed together but rather more irregular and oval in form, ~1/300th inch in the long diameter. The walls were made of closely packed cellules 1/2000th inch in diameter. No true bony cells could be found. When examined under polarized light at a power of 400 it showed a structure similar to that of horn or ivory.”

Histological descriptions then followed rapidly: of a fibronucleated tumor,151 “a section of the mass hardened in spirit showed bundles of fibrous tissue but not arranged so as to form a cancerous stroma; several simple round cells and masses of spindle shaped cells”;51 a “globular epithelioma”;152 a small round cell carcinoma;153 and a myxosarcoma including a woodcut of the histological appearances.116 Heiberg in 1861 described an adenoid cystic carcinoma under the then current term of cylindroma; this view was based on histological examination.154 Other probable adenoid cystic carcinomas were soon described.49,138 In the latter case histology showed “an epitheliomatous epulis resembling an adenoma of the breast.”12 In another case recorded as a cubular epithelioma,22 histology showed “the ground work to consist of well-developed fibrous tissue with large groups of cells arranged in some parts like a racemose gland and in other parts like tubular glands. In the center of most of these groups there was a lumen.” This was probably an adenoid cystic carcinoma, although it might have been an adamantinoma as it was said to resemble identically a “multilocular epithelioma” previously described in the upper jaw.

Sir William Fergusson must have had an interesting career, spanning as it did the development of both pathology and anesthesia. The circumstances when he performed his first operation in 184253 must have been very different from those when he removed a maxilla in 1872.67,155 On the latter occasion histology was available to show that the tumor was composed of fibrous tissue with islandlike and spindle-shaped nuclear bodies with a calcareous nodule in its center, which was probably an ossifying fibroma. He was certainly using chloroform by 1863.61

Anesthesia

In the early days the patient was held or tied down. Nobody records “dulling the patient with alcohol” but this must surely have been common; laudanum (i.e., morphine) appears to have been given only after the operation. Chloroform was introduced in 1847 and ether in 1842, but chloroform was usually the sole agent used for maxillectomy (Fig. 2.4).

Chloroform was in frequent use by the 1860s, even in the provinces. Unfortunately, the patient was often conscious during the greater part of the operation: “chloroform was administered to its full extent to begin with, but its inhalation was not continued afterwards.”52 Another report from Australia in 1868 tells us that it “was tried but abandoned.”156

It was often necessary to allow the patient to wake up during the operation if he or she was bleeding profusely. As late as 1870 it was customary to fix patients in the armchair as a precaution in case they did wake up.111 Patients often recovered from the chloroform and “spat the blood as is often the case on all bystanders.”157

Some thought that chloroform was dangerous because “the irritability of the glottis is weakened if not wholly lost, so that there must be the danger of the trickling of blood from the mouth into the glottis without the excitement of a cough for expelling it from the windpipe.”76 It was often necessary to suspend the administration of chloroform and allow the patient to recover consciousness because of the “danger of strangulation from the great amount of blood poured out.” For this reason Rose recommended carrying out the operation with the head hanging.158 Some surgeons remained unwilling to use chloroform until late in the century.159

In the early days chloroform was administered by sprinkling it on a piece of lint,79 but by 1860 it was being administered by a tube passed through one nostril.58 Later a special tubular inhaler was developed to be passed through one nostril45 but this method was rapidly displaced by Trendelenberg’s cannula. Trendelenberg had introduced a tracheostomy tube with a cuff in 1870.160 This cannula had been used for the administration of an anesthetic through a tracheostomy to the first patient to undergo total laryngectomy by Billroth in 1873,161 and it was used for a maxillectomy for a cylindroma by Heiberg in Germany in 1872.154 This method is the obvious way to avoid the dangers of hemorrhage during the administration of chloroform, and had become established by the 1880s: Bellamy in 1883 said “I was first inclined to do a prophylactic tracheotomy and to use Trendelenberg’s tamponade apparatus.”162

A further means of preventing pain was to freeze the line of incision with ether.156

Instruments

Although surgical instruments of many kinds had been available and used for centuries (Fig. 2.5) there were nonetheless some instances of great differences between the early 19th century and the present day. Two examples might suffice to emphasize this: first, the only form of illumination was natural daylight. Only one paper in the first 50 years comments on illumination. In Irving’s case in 1824 the patient was placed in an armchair opposite a window.163 The question of illumination is not otherwise discussed. Lighting must have been very difficult as efficient illumination, either by gas or electric light, did not come into general use until the 1880s. Second, artery forceps for the control of hemorrhage were not invented until the latter part of the century, although ligatures were available for the arteries, and indeed were used by Nivison in 1824.163 Fergusson’s textbook of 1870 shows that the vessel was held by a forceps and the ligature was applied.66

A common instrument was the cautery, of which there were two types: the actual cautery and the potential cautery. The actual cautery was a hot branding iron, whereas the potential cautery consisted of caustics of different sorts. Division of cautery into these two types was of ancient origin, and their use was described by Parey in the 17th century.164 The actual cautery was used to deal with carious bone. Parey felt that it was more effective than potential cauteries such as sulfuric acid, scalding oil, and molten sulfur, because it could be used more precisely, but that the potential cautery often had to be used because of the pain produced by the actual cautery! In the 19th century discussions as to the relative merits of the two continued: Liston (1821) felt that the actual cautery was preferable in maxillectomy because it was effective and the pain it produced was greater but momentary, whereas the pain of potential cautery persisted for several days.105

The term “actual cautery” continued to be used into this century: Ochsner wrote a paper entitled “Treatment of cancer of the jaw with the actual cautery” in 1923.10 The cautery he used was a simple soldering iron heated to red heat in a gas flame. He felt that it was important to hold the iron in place for at least a minute to destroy tissue up to 2 cm away. Also, he thought that the necrotic tissue thus formed stimulated the production of antibodies that attacked the cancer, a concept which reemerged some 50 years later with the cryosurgical probe. However, by 1926 the diathermy had almost completely replaced the use of soldering irons, as it requires no protection for the surrounding tissues, and may be employed with greater facility.165 The electrocoagulation was produced by a bipolar high-frequency current of the d’Arsonval type.166 A further extension of the principle of the actual cautery is cryosurgery, which was first used for maxillary carcinoma around 1970.167

An interesting illustration of the use of potential cautery is provided by a patient from Wales with a tumor of the palate who was eventually subjected to excision of the jaw in 1843, but who for some time had been under the care first of a “wild wart” doctor and then a wild wart doctress. These two practitioners had treated the tumor with external applications consisting of a mixture of clay, French brandy, and a caustic fluid, probably sulfuric acid.168 The Welsh wild wart doctors survive to this day and still have a successful practice for the treatment of basal cell carcinomas of the skin using mixtures of this kind.

There was much discussion about the best way of removing the bone; one of the common methods was the use of the lion-jawed forceps designed by Sir William Fergusson (Fig. 2.6).20 The use of the “chain saw” (i.e., Gigli’s saw) was popularized by Davies in 185846 and Heyfelder in 1857.169 The latter devised a blunt needle passed into the sphenomaxillary fissure to emerge in the zygomatic fossa, allowing a chain saw to be pulled through for division of the malar bone. He pointed out the advantages of the chain saw over the ordinary saw: the greater ease and rapidity with which the bones can be divided; the avoidance of splintering; and the facts that the parts are cut from behind forward, avoiding unintentional division by the saw, that corners can be rounded, and that the division of the bony parts can be effected in a very small space. He strongly criticized Desault’s procedure of boring a hole into the antrum with a punch and enlarging it with a short curved knife (“instrument tranchant en forme serpette”) because the walls of the antrum in many cases are not thinned. He clearly understood the principle of total excision for cancer when he stated that “all pathologists and operators on the upper jaw seem with one consent to deprecate the removal of tumors and especially cancerous with a sparing or niggardly hand, their usual counsel in practice being the extirpation of the whole jaw.” Another commonly used means of dividing bone was the Hayes saw.156

The speed with which these operations were performed can but leave us breathless. The length of the operation is only rarely recorded, but Hancock resected the entire upper jaw in 8 minutes in 1847,78 and Key in 20 minutes in 1833.96

Localized Removal

The first recorded partial removal of a maxillary tumor was that performed by Wiseman, surgeon to Charles II, reported in 1676:170

A man about twenty-eight years of age came out of the Country recommended to me with a Cancer of his left Cheek, stretching itself from the side of his nose close under the lower Eye-lid to the external Canthus, so making a compass downwards. It was broad in its basis, and rose copped like a Sugarloaf. It gleeted, and was accompanied with Inflammation and much pain. He had also some scirrhous glands under that Jaw. The extirpation of this Cancer had been attempted in the Country; but it growing afterwards bigger and threatening his Eye lately with inflammation, he hastned up, and importuned me to undertake it. I complied with his desire, and four or five days after having prepared all things ready, viz actual Cauteries, Digestives, Defensatives, Bandage, etc. Doctor Walter Needham and my Kinsman Jaques Wiseman being assisting. I pulled the Tumour toward me with one hand, during which I made my Incision close by the Eye-lid, and cut it smooth off as close to the Os jugulare as I could doe it, avoiding the Periosteum. The blood at first spurt out forcibly from many capillaries besides two considerable Arteries: we permitted them to bleed awhile. The lesser Vessels stopped of themselves, and we cauterized the greater afterwards. Then viewing our work, and observing some relique of the Cancer remaining above the external Canthus, we consumed it by actual cautery, and dressed up the Wound with our Digestive, with Embrocations, Desensatives, and moderate bandage to retain them. The third day we took off Dressings, saw it well disposed to digest, and dressed it as before. The second day after, dressing it again, the Cancer appeared rising from the side of the nose and Eye-lid; it also overspread the Cheekbone. I dressed it as I had done the time before, and the next time came prepared with actual cauteries, and consumed it all, then dressed it up with Lenients. From that time the Ulcer healed daily, and contracted in ten days space to the half; yet since then it begins to bud again here and there, which will put me upon a necessity of using the actual Cautery: and what account to give of it I yet know not.

According to Butcher a part of the upper jaw was removed by Acoluthus, a physician at Breslau in 1693. A woman had a turnout on the jaw after the extraction of a tooth. He enlarged the mouth with a cut, removed part of the swelling, together with four teeth, but was unable at once to get completely round it; “he attacked it several times at intervals of a few days, sometimes with cutting instruments, and sometimes with the actual cautery, and at last succeeded in curing his patient.”31 In 1770, White described a turnout of the antrum of two years’ standing. He removed it by a semicircular incision in the face, scooping away “matter like rotten cheese and many fragments of rotten bones”; the bony walls of the orbit were already destroyed. He preserved the eye, the optic nerve and part of the alveolus, but stopped at the dura which he could see and feel!171

Operations for tumors of the upper jaw were thus rarely attempted before 1800, and they are not mentioned at all in the standard 18th-century texts such as those by Bell, Heister, Hunter, and Pott.172–175 However, between 1800 and 1820 sporadic attempts were made with increasing frequency at localized excision of diseased tissue.

Localized removal of a turnout after elevating skin flaps, was performed by Dupuytren in 1818,176 by Liston in Edinburgh in 1821,105 by Irving a surgeon in Annan, Scotland on November 1, 1822,88,163 by Rogers in 1824 in New York,177 by Ballingal in 1827 in Edinburgh,21 and by Velpeau of Paris in 1829 and 1830.178 In all of these cases an incision was made in the face, the soft tissues of the cheek were elevated, and a tumor of the antrum was removed by traction on the tumor itself. No deliberate attempt was made to divide the bony attachments of the maxilla and such cases could not really qualify as maxillectomies.

Butcher also tells us that the scooping operation was practiced by Desault, Garengeot, Jourdain, Plaque and others, and has been “in modern times more especially brought under notice by Dupuytren, in 1820, and since by many surgeons.”31 Although Dupuytren argued that the greater part of the jaw might be excised, he did not do the operation himself.

A similar operation was being performed as late as 1837 in Germany: Dieffenbach described 17 cases, but only one of these could be classed as a subtotal maxillectomy, the remainder being localized resections of tumors affecting the hard palate or alveolus. The exception was an osteoma probably arising in the ethmoid sinuses which he removed preserving the alveolus and hard palate.47

Formal Maxillectomy

Guthrie in 1835 said that maxillectomy was one of the great improvements in modern surgery over the previous 16 years for which we were mainly indebted to the French.15 This statement suggests that the operation began to develop around 1820.

Lizars of Edinburgh, in 1826, proposed the entire removal of the superior maxillary bone, and described the procedure.108 Speaking of “polypi, or sarcomatous tumors, which grow in the antrum,” he says:

All the cases which have come within my knowledge (with the exception of one) wherein these sarcomatous tumors have been removed by laying open the antrum, have either returned or terminated fatally. I am, therefore, decidedly of opinion, that unless we remove the whole diseased surface, which can only be done by taking away the entire superior maxillary bone, we merely tamper with the disease, put our patient to excruciating suffering, and ultimately to death. An incision should be made through the cheek, from the angle of the mouth backward or inwards, to the masseter muscle, carefully avoiding the parotid duct, then to divide the lining membrane of the mouth, and to separate the soft parts from the bone, upwards to the floor of the orbit; second, to detach the half of the velum palati from palate bone. Having thus divested the bone to be removed of its soft coverings, the mesial incisive tooth of the affected side is to be removed; then the one superior maxillary bone to be separated from the other, at the mystachial and longitudinal palatine sutures, and also the one palate bone from the other at the same palatine suture, as the latter bone will also require to be removed either by the cutting pliers or a saw; third, the nasal process of the superior maxillary bone should be cut across with the pliers; fourthly, its malar process, where it joins the cheek bone; fifthly the eye, with its muscles and cellular cushion, being carefully held up by a spatula, the floor of the orbit is to be cleared of its soft connections, and the superior maxillary bone separated from the lacrymal and ethmoid bones with a strong scalpel. The only objects now holding the diseased mass are, the pterygoid processes of the sphenoid bone, with the pterygoid muscles. These bony processes will readily yield by depressing or shaking the anterior part of the bone, or they may be divided by the pliers, and the muscles cut with a knife. After the bone with its diseased tumor has been removed, the flap is to be carefully replaced, and the wound in the cheek held together by one or two stitches, adhesive plaster, and bandage. In no other way do I see that this formidable disease can be eradicated.

Lizars attempted the operation in December 1827 “for a medullary sarcomatous tumor of the antrum, from a miner or collier”, but had to abandon the operation because of bleeding. He tried again on August 1, 1829 and this time succeeded. He first tied the trunk of the temporal and internal maxillary arteries, and also the external jugular vein which had been divided in the first incision. He cut through the alveolar process and bony plate on the left side of the palatine suture, and completely separated the upper jaw with the saw, Liston’s forceps, and strong scissors, but the orbital plate was separated from the eyeball by the handle of the knife. The tumor was medullary sarcomatous, and a portion of it, attached to the pterygoid process of the sphenoid bone, could not be detached, but part of the malar bone involved in the disease was removed. On the 16th day the wound had healed and she left the house on that day. Three days after “she expired suddenly, but no examination was permitted.” He performed a further successful operation on 10 January 1830.179

A very similar procedure was performed by Syme, also at the Edinburgh Royal Infirmary on May 15, 1829.131 He made a cruciate incision and, after exposing the tumor, divided the malar bone with a saw and pliers, divided the nasal process of the maxillary bone, and cut through the hard palate using cutting pliers after having extracted one of the incisor teeth. He therefore probably did the operation a few weeks before Lizars, although Lizars gave the first description.

The early French literature is reviewed very thoroughly by Gensoul in his monograph of 1833.180 He describes operations performed by Garengeot, Desault, and Dupuytren up to 1824. He records the great pains he took to find out what operations were actually performed, both by reading the contemporary accounts and by talking to those present at these operations. His research can be summarized as showing that all the procedures performed to 1827 consisted of an incision on the face followed by piecemeal removal of diseased tissue; no formal excision had been attempted. Gensoul then described his own patient, a 17-year-old boy with a 2-year history of a swelling in the superior part of the canine fossa, which he described as a hyperostosis (Fig. 2.7). The tumor measured 7¾ × 7½ inches (197 mm × 190 mm) with a circumference of 16¼ inches (413 mm). After much thought and consultation with colleagues he embarked on an operation on May 26, 1827, at the Hotel Dieu in Lyon. After making three incisions in the skin of the face he elevated skin flaps. Then he used a mallet and chisel to divide the lateral wall of the orbit close to the frontozygomatic suture, passed the chisel as far as the pterygomaxillary fissure, and divided the frontal process of the zygoma. Next he applied a very large chisel to the inner canthus and passed it through the lacrimal bone. He divided the ascending process of the nasal bone in a similar manner. He used the knife to divide the soft tissues of the nasal ala from the maxilla, removed the first upper incisor on the left side, and divided the hard palate. Finally, to detach the maxilla from the pterygoid process, he plunged the chisel through the orbit and through the tumor, dividing the superior maxillary nerve, and used the chisel to bevel the specimen into the mouth. Shortly afterwards the patient fainted, but ultimately recovered! This is clearly the first account of a deliberate excision of the upper jaw.

Gensoul also did at least six other similar procedures, some for cancer, one with a 5-year cure. Unusually for that time, he followed his patients for upwards of 5 years and also recorded the size of the tumors, and at one point frankly admits a diagnostic mistake! Even more unusually, he deliberately delayed publication for 6 years to assess the long-term effects. His monograph runs to 77 pages, and in addition describes excision of the lower jaw. Gensoul also acknowledged Lizars’ claim to have done the first operation, an apparent reference to Lizars’ System of Anatomical Plates, published in 1826.

In the early 1850s there was a fairly vicious correspondence under pseudonyms such as “studens chirugiae” or “chirurgus”130,181 in the medical press about the question of who did the first maxillectomy: Lizars, Syme, or Gensoul. Who it was is of little consequence, except perhaps to Lizars, Syme, and Gensoul at the time! Such claims for scientific precedence are common: they tell us that the procedure was not a “maverick” out of its time, but rather that surgery had progressed to the point where the operation was feasible and several surgeons in different countries had decided to try it, indicating that the topic was one of general interest. The main countries contributing to this development were France and Great Britain and, to a lesser extent, Germany. The US Surgeon General’s Catalogue tells us that the procedure did not spread to other European countries until the second half of the 19th century.182 It was first performed in Belgium in 1845 by Heylen,183 in Poland in 1852 by Klose,184 in Italy in 1857 by Gianflone185 (a previous resection for necrosis had been reported in 1850 by Moretti),186 in the Netherlands in 1857 by Leonides van Praag,102 in Austria in 1857 by Dehler,187 in Portugal in 1862 by Barbosa,188 in Russia in 1862 by Kade,95 in Spain in 1864 by Rosa189 (one case for necrosis had been performed by Toca in 1858190), and in Finland in 1873 by Estlander.191

Resection of both upper jaws was first performed by Heyfelder in Erlangen, Germany in 1844.84 A report was given in English by his son Oscar in 1857 in the Dublin Journal of Medical Science; Dublin being one of the main centers for this procedure, notably under Butcher, a name now forgotten. The operation was performed for a large “pseudo-plasma” arising from the palate, pushing the nose forward. He raised a large bilateral flap up to the inferior orbital margin and then formally excised both maxillae, preserving the nose. No attempt was made to provide a prosthesis. The patient returned to work but died 15 months later of a recurrence in the frontal bone.169 Oscar Heyfelder stated that the indications for the removal of both upper jaws included the following:

• 
  

  Necrosis and caries

  
  
• 
  

  Benign tumors including enchondroma and osteosarcoma

  
  
• 
  

  Malignant tumors including epithelial cancer (cancroid of Virchow), cancer gelatiniforme, carcinoma medullare, and cystocarcinoma.

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