EPITHELIOID*. INVOLVING BOTH THE UPPER AND LOWER LIPS AND THE INSIDE3 OF THE CHEEKS; FORMATION OF A NEW LOWER, AND RE-MODELLING OF THE UPPER LIP, &c. I By Du. J. Ewart,
Officiating Surgeon
to
the Presidency General
Hospital,
Calcutta.
William Allen, aged 40, a West Indian Negro, contracted syphilis about two years ago, for which he seems to have been salivated. The teeth were loosened, the gums spongy, and these with the insides of the cheeks became ulcerated. From thafe time ulceration and salivation have been constantly present. About a year ago the disease involved the greater part of the lower lip. The case had then been pronounced to be an exemplification of epithelioma. Although anti-syphilitics had succeeded in removing evidences of syphilis, the increasing thickening and ulceration about the mouth, as also an epithelomatous condition of the right groin, in no way yielded to the application of local agents, or of constitutional remedies. On admission into my ward. 011 29th June, Allen's condition was anything but promising. The lower lip, a great portion of the inner surface of the upper lip, with a considerable part of the insides of both cheeks, were thickened and ulcerated from cancerous growth in a condition proceeding to rapid degeneration. He had suffered from enlargement and suppuration of the left parotid gland. This had been opened. But the abscess had not been quite repaired. On admission, a corresponding condition on the right side complicated the case. This was opened, and a large quantity of offensive pus evacuated by daily syringing out with carbolic acid lotion, and poulticing; this abscess was eventually all but healed up in about ten days. There was also an epithelioma in the right groin, extending in an unbroken line from the level of the anterior spinous process of the ileum downwards, between the scrotum and thigh, to within an inch of the anus. The salivation (not now mercurial) was constant, the fluid pouring from the mouth, night and day, in great abundance. In spite of repeated gargling with Condy's fluid and carbolic acid wash alternately, the smell issuing from the ulcerated masses was often most offensive, poisoning the surorunding air, and rendering the unhappy patient as loathsome an object, as could well be imagined, both to himself and his attendants. He was fed entirely on milk, soup, and broths, all power of mastication being absent, owing to the impossibility of using the muscles, on account of the pain occasioned by
INDIAN
MEDICAL
?NOVEMBER! 1. 18 71.
GAZETTE.
BEFORE
OPERATION. FIG. I.
mmmum
immediately IMMEDIATELY
after AFTER
operation. OPERATION.
FIG. II. 6
WEEK'S
AFTER
FIG III.
OPERATION.
November 1,
1871.]
A MIRROR OF HOSPITAL PRACTICE.
the disease. He was anaemic; pulse weak and easily compressed, and beating at the rate of from 120 to 140 in the minute on the slightest exertion. His appetite was greatlyimpaired, and sleep could only be obtained by the use of hydrate of chloral, opium or morphia. Owing to the trickling down of the discharge into the glottis, if he lay in the recumbent posture, he slept in a sitting position with his head thrown forward and resting on the arm of a chair placed by his bed. Quinine and ferruginous tonics, milk, beef-tea and broths, were prescribed ; and hydrate of chloral, opium or morphia were given to produce sleep. He improved under this management, and the progress of the suppurating glands in the neck was such as to justify the conclusion that they were not the seat of cancerous growth. I, therefore, resolved to remove the whole of the disease, to endeavour to make him a new under lip, and after the extirpation of the cancerous material from the inside of the upper lip and cheeks, to re-model the form of the upper lip also. 12th July.?The patient, having been prepared by a dose of castor-oil, given on the previous evening, was put under the influence of chloroform by Dr. S. Coull Mackenzie at 8 a.m. I was further most ably assisted by Drs. Le\fis, Lyons, and Mr. Grassby. The front teeth having been extracted, the site of the ascent of the facial arteries over the body of the lower jaw carefully noted, and the coronary arteries commanded by Dr. Lewis and Dr. Lyons, the whole of the lower lip was removed by a couple of strokes of the knife, and all arterial haemorrhage stopped by torsion. A perpendicular incision was now carried along the mesial line for an inch and a half below the chin, and continued in a curvilinear manner outwards and upwards over the right side of the jaw up to the seat of the facial artery. This flap was now dissected up close to the periosteum. "When this was done, it was found impossible to reach the whole of the extent of the disease in the inside of the cheek, without also making an incision of about an inch outwards from the angle This was done, and every vestige of thickened of the mouth. and indurated structure carefully cut away. Precisely the same plan was followed on the left side ; but it was found necessary to extend the incision from the angle of the mouth, to about three inches, before all the foreign growth could be extirpated with ease and security. Fully one-half of the substance of the diseased upper lip was now sliced away ; and all haemorrhage having been completely checked, co-aptation of the raw surfaces of the new lower lip in the mesial line was effected by a couple of hair-lip pins and a few horsehair sutures, whilst the lips of the wounds in the respective cheeks were held securely together by silver sutures. To give additional security, a hair-lip pin was used at each angle of the mouth instead of a common silver suture. The lines of the incisions were covered with strips of lint soaked in carbolic oil, and the parts kept in position by means of strapping and bandaging. The wound below the chin was dressed with the same material, and left to heal up by granulation. A grain of morphia was now given, and the patient put to bed. Diet as before. In the evening, the pulse had fallen to 100; he had slept, during the day, on his back?a comfort which he had not enjoyed for several months. He bad drunk some milk through His skin was moist and cool. At bed-time, another a tube. grain of morphia was given, which produced several hours' sound sleep. His diet was ordered to consist of six pints of milk. pure, as tested by the lactometer, 6 ounces of good port wine, 6 ounces of sago with a sufficiency of sugar, and four His eggs to be eggs?any or all to be increased if necessary. given in the form of flip with the port wine. Quinine and iron to be also continued. On the 16th, the hare-lip pins and horsehair sutures were removed from the new lip, and all the other sutures from the wounds in the cheeks; union by the first intention having been complete throughout, without the formation of any pus, excepting in the track of the pins only. The required support Since the operation, was afforded by strapping and bandaging. the mouth has been freely syringed out with carbolic aoid water, three times a da}"; and this practice was ordered to be systematically adopted until cicatrization of the wounds inside had been completed. From this date to the 23rd, the patient progressed favourably in every way. He then suffered from dysphagia, apparently Still he succeeded in swallowing, caused by pharyngitis. though sometimes with much difficulty, a considerable proportion of the liquid nutriment allowed. On the 25th, the dysphagia had diminished. It, however, from time to time caused me anxiety, inasmuch as I feared a return of the cancerous affection in the deep glands of the throat; and he was for seme
J
235
time ordered to be fed by rectum as well as by the mouth. This difficulty in swallowing continued more or less till the 3rd of when it altogether disappeared. August, On the 21st of August, the reparation of parts had been but the epithelioma of the right groin hereinbefore completed; alluded to, remained to be dealt with. Since the operation of the 12th July, for the extirpation of the cancer of the lip, &c., and the formation of a new lip, little or no change, for better or worse, had been observed in this complication. On this date, assisted by Drs. Palmer, Lewis and Lyons, I pared off the surface, as deeply as was consistent with safety, throughout, and brought the parts into correct co-aptation by means of a series of hare-lip pins, silver and horsehair sutures, and the limb was so placed and fixed as to relieve all tension or strain upon these mechanical appliances, until the 26th, when all the sutures wore removed, and adhesion was found to have taken place in the whole length of the disease, measuring upwards of nine inches. The only breaches in this effort at repair were in the course of some of the sutures, which had ulcerated their way through, to a certain extent; but these soon healed up and cicatrized. At the present time September 15th, the patient is in comparatively robust health ; but whether the disease will return or not it is impossible to say. Remarks.?The accompanying figures illustrate the appearance of the patient, (I.) before, (II-) immediately after the operation; and (III.) when complete repair had become established. The two first have been lithographed from sketches made by my friend Dr. Lewis; the third from a photograph by Mr. Humphidge of Park Street. Allen cannot succeed in growing a moustache and beard. The consequence is that his looks are not quite so prepossessing as they would otherwise have been. The relief from distress has been complete, and there is no indication of a return of the disease. There is more contraction of the mouth than I anticipated ; but as there is no difficulty in taking nourishment, and as the utmost limit of contraction of the cicatrix tissue seems to have been reached, there is no good reason for interference. Should, however, the contraction increase, it will be an easy matter to enlarge the opening to any extent deemed desirable. He eats, sleeps, and speaks well and distinctly, and his general health is all that can be wished for, considering the wretched condition he was in, when the first
operation
was
performed.
Officiating Surgeon
to
the Presidency General
Hospital,
Calcutta.
William Allen, aged 40, a West Indian Negro, contracted syphilis about two years ago, for which he seems to have been salivated. The teeth were loosened, the gums spongy, and these with the insides of the cheeks became ulcerated. From thafe time ulceration and salivation have been constantly present. About a year ago the disease involved the greater part of the lower lip. The case had then been pronounced to be an exemplification of epithelioma. Although anti-syphilitics had succeeded in removing evidences of syphilis, the increasing thickening and ulceration about the mouth, as also an epithelomatous condition of the right groin, in no way yielded to the application of local agents, or of constitutional remedies. On admission into my ward. 011 29th June, Allen's condition was anything but promising. The lower lip, a great portion of the inner surface of the upper lip, with a considerable part of the insides of both cheeks, were thickened and ulcerated from cancerous growth in a condition proceeding to rapid degeneration. He had suffered from enlargement and suppuration of the left parotid gland. This had been opened. But the abscess had not been quite repaired. On admission, a corresponding condition on the right side complicated the case. This was opened, and a large quantity of offensive pus evacuated by daily syringing out with carbolic acid lotion, and poulticing; this abscess was eventually all but healed up in about ten days. There was also an epithelioma in the right groin, extending in an unbroken line from the level of the anterior spinous process of the ileum downwards, between the scrotum and thigh, to within an inch of the anus. The salivation (not now mercurial) was constant, the fluid pouring from the mouth, night and day, in great abundance. In spite of repeated gargling with Condy's fluid and carbolic acid wash alternately, the smell issuing from the ulcerated masses was often most offensive, poisoning the surorunding air, and rendering the unhappy patient as loathsome an object, as could well be imagined, both to himself and his attendants. He was fed entirely on milk, soup, and broths, all power of mastication being absent, owing to the impossibility of using the muscles, on account of the pain occasioned by
INDIAN
MEDICAL
?NOVEMBER! 1. 18 71.
GAZETTE.
BEFORE
OPERATION. FIG. I.
mmmum
immediately IMMEDIATELY
after AFTER
operation. OPERATION.
FIG. II. 6
WEEK'S
AFTER
FIG III.
OPERATION.
November 1,
1871.]
A MIRROR OF HOSPITAL PRACTICE.
the disease. He was anaemic; pulse weak and easily compressed, and beating at the rate of from 120 to 140 in the minute on the slightest exertion. His appetite was greatlyimpaired, and sleep could only be obtained by the use of hydrate of chloral, opium or morphia. Owing to the trickling down of the discharge into the glottis, if he lay in the recumbent posture, he slept in a sitting position with his head thrown forward and resting on the arm of a chair placed by his bed. Quinine and ferruginous tonics, milk, beef-tea and broths, were prescribed ; and hydrate of chloral, opium or morphia were given to produce sleep. He improved under this management, and the progress of the suppurating glands in the neck was such as to justify the conclusion that they were not the seat of cancerous growth. I, therefore, resolved to remove the whole of the disease, to endeavour to make him a new under lip, and after the extirpation of the cancerous material from the inside of the upper lip and cheeks, to re-model the form of the upper lip also. 12th July.?The patient, having been prepared by a dose of castor-oil, given on the previous evening, was put under the influence of chloroform by Dr. S. Coull Mackenzie at 8 a.m. I was further most ably assisted by Drs. Le\fis, Lyons, and Mr. Grassby. The front teeth having been extracted, the site of the ascent of the facial arteries over the body of the lower jaw carefully noted, and the coronary arteries commanded by Dr. Lewis and Dr. Lyons, the whole of the lower lip was removed by a couple of strokes of the knife, and all arterial haemorrhage stopped by torsion. A perpendicular incision was now carried along the mesial line for an inch and a half below the chin, and continued in a curvilinear manner outwards and upwards over the right side of the jaw up to the seat of the facial artery. This flap was now dissected up close to the periosteum. "When this was done, it was found impossible to reach the whole of the extent of the disease in the inside of the cheek, without also making an incision of about an inch outwards from the angle This was done, and every vestige of thickened of the mouth. and indurated structure carefully cut away. Precisely the same plan was followed on the left side ; but it was found necessary to extend the incision from the angle of the mouth, to about three inches, before all the foreign growth could be extirpated with ease and security. Fully one-half of the substance of the diseased upper lip was now sliced away ; and all haemorrhage having been completely checked, co-aptation of the raw surfaces of the new lower lip in the mesial line was effected by a couple of hair-lip pins and a few horsehair sutures, whilst the lips of the wounds in the respective cheeks were held securely together by silver sutures. To give additional security, a hair-lip pin was used at each angle of the mouth instead of a common silver suture. The lines of the incisions were covered with strips of lint soaked in carbolic oil, and the parts kept in position by means of strapping and bandaging. The wound below the chin was dressed with the same material, and left to heal up by granulation. A grain of morphia was now given, and the patient put to bed. Diet as before. In the evening, the pulse had fallen to 100; he had slept, during the day, on his back?a comfort which he had not enjoyed for several months. He bad drunk some milk through His skin was moist and cool. At bed-time, another a tube. grain of morphia was given, which produced several hours' sound sleep. His diet was ordered to consist of six pints of milk. pure, as tested by the lactometer, 6 ounces of good port wine, 6 ounces of sago with a sufficiency of sugar, and four His eggs to be eggs?any or all to be increased if necessary. given in the form of flip with the port wine. Quinine and iron to be also continued. On the 16th, the hare-lip pins and horsehair sutures were removed from the new lip, and all the other sutures from the wounds in the cheeks; union by the first intention having been complete throughout, without the formation of any pus, excepting in the track of the pins only. The required support Since the operation, was afforded by strapping and bandaging. the mouth has been freely syringed out with carbolic aoid water, three times a da}"; and this practice was ordered to be systematically adopted until cicatrization of the wounds inside had been completed. From this date to the 23rd, the patient progressed favourably in every way. He then suffered from dysphagia, apparently Still he succeeded in swallowing, caused by pharyngitis. though sometimes with much difficulty, a considerable proportion of the liquid nutriment allowed. On the 25th, the dysphagia had diminished. It, however, from time to time caused me anxiety, inasmuch as I feared a return of the cancerous affection in the deep glands of the throat; and he was for seme
J
235
time ordered to be fed by rectum as well as by the mouth. This difficulty in swallowing continued more or less till the 3rd of when it altogether disappeared. August, On the 21st of August, the reparation of parts had been but the epithelioma of the right groin hereinbefore completed; alluded to, remained to be dealt with. Since the operation of the 12th July, for the extirpation of the cancer of the lip, &c., and the formation of a new lip, little or no change, for better or worse, had been observed in this complication. On this date, assisted by Drs. Palmer, Lewis and Lyons, I pared off the surface, as deeply as was consistent with safety, throughout, and brought the parts into correct co-aptation by means of a series of hare-lip pins, silver and horsehair sutures, and the limb was so placed and fixed as to relieve all tension or strain upon these mechanical appliances, until the 26th, when all the sutures wore removed, and adhesion was found to have taken place in the whole length of the disease, measuring upwards of nine inches. The only breaches in this effort at repair were in the course of some of the sutures, which had ulcerated their way through, to a certain extent; but these soon healed up and cicatrized. At the present time September 15th, the patient is in comparatively robust health ; but whether the disease will return or not it is impossible to say. Remarks.?The accompanying figures illustrate the appearance of the patient, (I.) before, (II-) immediately after the operation; and (III.) when complete repair had become established. The two first have been lithographed from sketches made by my friend Dr. Lewis; the third from a photograph by Mr. Humphidge of Park Street. Allen cannot succeed in growing a moustache and beard. The consequence is that his looks are not quite so prepossessing as they would otherwise have been. The relief from distress has been complete, and there is no indication of a return of the disease. There is more contraction of the mouth than I anticipated ; but as there is no difficulty in taking nourishment, and as the utmost limit of contraction of the cicatrix tissue seems to have been reached, there is no good reason for interference. Should, however, the contraction increase, it will be an easy matter to enlarge the opening to any extent deemed desirable. He eats, sleeps, and speaks well and distinctly, and his general health is all that can be wished for, considering the wretched condition he was in, when the first
operation
was
performed.
