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Epithelioma of the Mouth. 
 
 BY 
 
 H. I. Ostrom, M. D. 
 
 Author of "A Treatise on the Breast and its Surgical 
 Diseases;" Member of the American Institute 
 of Homeopathy ; the Homeopathic Med- 
 ical Society of the County of 
 Neiv York, etc., etc. 
 
 New York: 
 A. L. CHATTERTON COMPANY. 
 
 1885. 
 
Copyright, 1885, 
 H. I. OSTROM, M. D. 
 
 Martin & Niper, 
 
 Printers, Electrotypers and Binder} 
 
 218 Fulton St., Brooklyn, N. Y. 
 
PREFACE. 
 
 The following monograph is the out growth 
 of a series of investigations, entered into in 
 the course of professional study, for the 
 purpose of elucidating to the author, some 
 obscure points in the pathology, ethiology, 
 and treatment of epithelioma of the mouth. 
 Originally designed for personal use only, 
 the notes made, early assumed the character 
 of a study of the subject, which, in accord- 
 ance with urgent requests, is now presented 
 to the profession. 
 
 H. I. OSTEOM. 
 
 139 West 45th St., July, 1885. 
 
CONTENTS. 
 
 CHAPTER I. 
 
 The Epithelium of the Mouth. 
 
 CHAPTER II. 
 
 Epithelioma of the Mouth. 
 
CHAPTER I. 
 The Epithelium of the Mouth. 
 
 For our present purpose it is convenient 
 to study the epithelium of the mouth. 
 
 This will be found to include the lining of 
 the buccal cavity, the covering of the tongue, 
 and the essential part of all the glands that 
 pour their secretions in front of the pharynx. 
 
 Before the fourth week in the life of the 
 human embryo, there is developed at the 
 lower part of the face a broad, transverse 
 cleft. This is the primitive mouth, (strom- 
 odocum), and while the initial step in its 
 development is a growth inwards of that 
 part of the face which corresponds to the 
 embryonic depression, the future enlargement 
 of the buccal cavity depends more upon the 
 growth outwards of the fronto nasal process 
 in the middle, the superior maxillary pro- 
 cesses on the sides, and the mandibular 
 plates, which are continuous with the 
 maxillary processes, than upon the extension 
 inwards, the deepening of the primitive 
 cleft. 
 
EPITHELIUM OF THE MOUTH 13 
 
 Developed as it is from the face, and 
 carrying with, it the covering of the face, 
 the investing membrane of the mouth is 
 derived from the epiblastic layer of the 
 blastoderm. This depression of the epiblast, 
 the future mouth, forms a sac, that is at first 
 closed posteriorly, having only an anterior 
 opening between the processes above men- 
 tioned. Not until the eighth or ninth week is 
 a communication established between the 
 mouth and the pharynx — the latter is of 
 mesoblastic origin — by breaking down the 
 anterior wall of one cavity, and the posterior 
 wall of the other. 
 
 It is thus seen, that the mouth and the 
 pharynx are in the embryo, two separate 
 non- connecting cavities, the first having its 
 origin in the epiblastic layer, the second in 
 the hypoblastic layer, and visural mesoblast. 
 
 This embryonic differentiation suggests the 
 possibility of a corresponding distinction 
 being made between the future functions, of 
 these two divisions of the alimentary canal ; 
 but also, and especially because of its bearing 
 upon the etiology of the diseases of the 
 mouth, of establishing a relation between 
 the blastodermic layer represented, and the 
 
14 EPITHELIUM OF THE MOUTH 
 
 form of disease that it develops. It must be 
 confessed, however, that this anticipation 
 has thus far been only partially realized ; for 
 while the differentiation of the embryo into 
 layers, and the development of these layers 
 into organs and parts with an unchanging 
 regularity and exactness, has been demon- 
 strated, it cannot at present be shown that, 
 for example, the glands of the mouth, and 
 the glands of the pharynx, may not develop 
 exactly similar diseases, and present indis- 
 tinguishable histological conditions. 
 
 The usual method of the development of 
 glands — by a prolongation inwards of the 
 epithelial layer upon which the secreting 
 organ is to open, — renders it probable that 
 the mouth, whatever may be its mature con- 
 formation, when viewed in its simplest form, 
 presents a continuous layer of tissue, with- 
 out depressions or elevations ; and that the 
 variously formed recesses that constitute the 
 salivary and mucous glands, are a later 
 development, to meet the requirements of the 
 growing organism. 
 
 This anatomical distinction, which marks 
 the functionally active mouth, forms two 
 convenient divisions for studying the buccal 
 
EPITHELIUM OF THE MOUTH 15 
 
 epithelium, — the non-glandular, and the 
 glandular tissue ; but let it be emphasized 
 that they have the same genesis, and that 
 their histological distinctions are the 
 result of functional requirements. 
 
 The features by which epithelial tissue is 
 recognized, are few, but well marked. The 
 cells though variously shaped are nucleated, 
 and everywhere in close apposition, or are 
 held together by a cohesive substance that is 
 not always apparent. They are arranged on 
 a base of connective tissue — the membrana 
 propria, or in the case of glands, the stroma 
 — in the form of one or more layers, in which 
 there is no vascular system, but in which the 
 supply of nerves is sometimes quite abun- 
 dant. These layers of epithelial cells 
 constantly cover the surface of the body, and 
 those canals and cavities that communicate 
 with the surface. They may, therefore, be 
 looked upon as defining the body, as con- 
 stituting a natural boundary to the organism, 
 and as everywhere presenting a surface upon 
 which contact with external objects is 
 effected. 
 
 The definiteness with which epithelial 
 tissue, as distinguished from the bodies that 
 
16 EPITHELIUM OF THE MOUTH 
 
 enter into its construction, is recognized, is 
 not found to be equally true of the individual 
 epithelial cells, for these, when isolated, are 
 not always clearly characteristic ; and 
 especially when young and immature, before 
 they have assumed either the form or func- 
 tion of a special variety, are not distinguish- 
 able from other cells while in a transition 
 state, or from other varieties of epiblastic 
 derivatives. A reason for this exists in the 
 fact that epithelial cells are not permanent 
 bodies. With peculiar rapidity, they pass 
 through their different stages of evolution, 
 and do not accomplish their physiological 
 perfection until immediately before they are 
 destroyed, or thrown off. Hence, it is 
 apparent that as one variety of epitkeliuni 
 can pass into any other variety, if the con- 
 ditions and requirements are favorable for 
 such a metamorphosis, it is impossible to 
 predict the form that the young cell may 
 assume. 
 
 Functionally active epithelial cells are 
 not provided with a cell wall, but are 
 composed of protoplasm in the form of a fine 
 riticulum, in the meshes of which is found 
 the peculiar cell contents. The nucleus and 
 
EPITHELIUM OF THE MOUTH 17 
 
 nuceoli are also composed of a riticulum, 
 that is apparently continuous with that of 
 the cell body, but the nucleus is constantly 
 surrounded by a double contoured limiting 
 membrane. Such naked bodies are young 
 cells, of which the outer zone of protoplasm 
 has not hardened into "formed material," 
 to give a protective envelope. 
 
 The contents of epithelial cells will be found 
 to vary with their function, and the period of 
 functional activity at which they are exam- 
 ined, for all epithelial cells a.re secreting bod- 
 ies, the nucleus probably possessing an elect- 
 ive power over the substance secreted and 
 elaborated. 
 
 The non-glandular, or investing epithelium 
 of the mouth, which is directly continuous with 
 the epithalial covering of the face, belongs to 
 the stratified pavement variety. It is composed 
 of several layers of differently shaped cells, the 
 deeper or attached layer being generally col- 
 umnar, while the superficial layer presents 
 flattened scales, that slightly overlap each 
 other,and are not always provided with nuclei. 
 Between these layers may be distinguished 
 an intermediate layer of polygonal cells, 
 having blunt angles. 
 
18 EPITHELIUM OF THE MOUTH 
 
 The regeneration of epithelium, a regener- 
 ation made necessary by the constant des- 
 quamation of the cells of the superficial lay- 
 er, always takes place from the deeper layer, 
 the cells of which do not lie in immediate 
 contact with each other, but are united by 
 means of spines and ridges — probably the 
 continuation of the reticulum of the cell body 
 — which, projecting from the surface of one 
 cell, are received in corresponding depressions, 
 or upon similar spines of other cells, by 
 which means are formed intercellular chan- 
 nels. 
 
 These tubes probably constitute a vascular 
 system, that of necessity changes with the 
 multiplication of the cells, and have no other 
 walls than the limitations of the epithelial 
 cells. It is not unlikely that nerves also 
 occupy these channels. 
 
 Below the columnar epithelial cells, and 
 resting upon a layer of loose connective tissue 
 that serves to unite the buccal mucous 
 membrane to the underlying parts, is the 
 corium, a structure made up of connective 
 tissue fasciculi and elastic fibres, which give 
 rise to papillae, the whole of especial interest 
 in the present study, as being the tissue that 
 
EPITHELIUM OF THE MOUTH 19 
 
 contains and supports the numerous mucous 
 glands found in this region. 
 
 The epithelial covering of the tongue and 
 soft palate differs somewhat from the strati- 
 fied epithelium found on the cheeks, lips 
 and hard palate. It accurately invests the 
 papillae of the tongue, and the taste buds, 
 dipping down between these ; and over the 
 circumvallate papillae at the base of the organ 
 becomes very thick, entirely concealing the 
 minute secondary papillae, that are developed 
 from the apex of some of the conical papillae. 
 
 The epithelial covering of the secondary 
 papillae is characteristic. Over these eleva- 
 tions the epithelium is arranged as a 
 separate horny layer, prolonged into pro- 
 cesses that extend far beyond the papillae 
 that it covers. From this circumstance these 
 papillae have been called filiform. 
 
 The epithelial cells of the filiform papillae 
 are usually more or less hard, containing 
 only a small proportion of protoplasm, and 
 frequently no nucleus. As with other epithe- 
 lial cells, they are constantly being thrown 
 off, and their place supplied from the deeper 
 layers. 
 
 The larger portion of the soft palate is 
 
20 EPITHELIUM OF THE MOUTH 
 
 covered with scaly and stratified epithelium, 
 that presents no marked differences from the 
 investment of other parts of the mouth ; but 
 at the upper portion the epithelium is 
 ciliated, and in places columnar. . 
 
 In common with other mucous membranes, 
 that which lines the cavity of the mouth is 
 constantly bathed with mucous. This secre- 
 tion is accomplished either by the investing 
 epithelial cells, which elaborate murine 
 within their protoplasm, and discharge it, 
 probably at the same time, and with the cell 
 body either intact or destroyed ; or by 
 minute glands situated within the sub-mucosa. 
 
 In reference to the first method, it is to be 
 noted that the columnar cells are especially 
 concerned with the formation of mucous. 
 These cells often become so much distended 
 with mucigen that they lose their columnar 
 shape and assume the chalice or goblet form, 
 by bulging near the free border. At the 
 same time the nucleus is found pressed 
 against the inner and attached part of the 
 cell. From the distended part of the cell, 
 when this does not burst, a drop of mucous 
 may frequently be seen to exude, which 
 increases the peculiar form of the cell. The 
 
EPITHELIUM OE THE MOUTH 21 
 
 scaly or stratified cells do not, to any extent, 
 secrete mucous ; and these occupying the 
 most superficial layer of the membrane, it is 
 probable that the deeper epithelium of the 
 mouth, though columnar, is more especially 
 for the purpose of regenerating the outermost 
 layer of cells, and of less service in secreting 
 mucous ; it is not, however, denied that, 
 under certain circumstances, they may per- 
 form this office. 
 
 It thus appears that the buccal mucous is 
 almost exclusively of glandular manufacture, 
 and is to a limited degree only, elaborated 
 by the investing epithelium. 
 
 A description of the epithelium of the buccal 
 mucous glands would, in a great measure, be a 
 repetition of what has been already said con- 
 cerning the epithelial investment of the mouth. 
 For, as we have seen, to a certain but varying 
 degree, all mucous epithelium is glandular, 
 that is to say, it performs the function of 
 secretion. 
 
 The mucous glands of the mouth are 
 minute, compound acinous organs — similar 
 to the salivary glands — that are formed by a 
 prolongation of the investing epithelium, into 
 the sub-mucosa. They are lined with 
 
22 EPITHELIUM OF THE MOUTH 
 
 columnar cells, which when active, assume 
 the chalice shape referred to. 
 
 The glands are situated on the inner side 
 of the lips, principally the lower, on the 
 cheeks, on the hard and soft palate, beneath 
 the lymph follicles at the base of the tongue, 
 and behind the lingual V near the papillae 
 vallata and foramen caecum. On the inferior 
 surface of the tip of the tongue, the glands 
 form two elongated patches — the glands of 
 Blandin and Nuhn — the ducts of which open 
 on each side of the fraenum linguce. 
 
 The ducts of the buccal mucous glands are 
 usually very short, and are lined with 
 columnar epithelium ; the gland itself is filled, 
 rather than lined, with the same variety of 
 cells. 
 
 The other glands of the mouth, in the 
 function and construction of which epithelial 
 cells bear a principal part, are the salivary 
 glands. These are arranged in three pairs. 
 only two pairs of which are situated in the 
 mouth, but the parotid glands are included 
 among the buccal glands, because their func- 
 tion does not differ essentially from the other 
 salivary glands, and, also, because their se- 
 cretion is poured into the month, together 
 
EPITHELIUM OF THE MOUTH 23 
 
 with that from the sub-maxiliary and lingual 
 
 glands. 
 
 The salivary glands belong to the group of 
 acinous glands, and in every instance consist 
 of a variously branched tube, lined with 
 epithelium. The alveoli or terminal branches, 
 are lined with large tessellated epithelium, 
 and the other part of the tube with columnar 
 epithelium. These salivary tubes pass in 
 different directions within the interior of the 
 gland, and perform an important part of the 
 process of secretion. The} 7 are not to be 
 confounded with the excretory duct of the 
 gland, the office of which is probably 
 largely mechanical in assisting the flow of the 
 saliva from the gland. The salivary tubes 
 are not possessed of muscular fibres. 
 
 In the alveoli of the sub- maxillary and 
 sub-lingual glands are found two species of 
 epithelial cells. Mucous cells, which are 
 large and pyramidal, with their apex towards 
 the centre of the alveolus, and their nucleus 
 almost in contact with the basement mem- 
 brane ; and small, granular, irregular cells, 
 united in groups, in the form of crescents, 
 that are usually situated at the base of the 
 alveolus, when their convexity is against the 
 
24 EPITHELIUM OF THE MOUTH 
 
 basement membrane, and their concavity is 
 occupied by the mucous cells ; some- 
 times these crescents are found in the centre 
 of the alveolus, between two mucous cells. 
 
 These cells contain a serous albuminous 
 fluid, which, mingling with the murine of 
 the mucous cells, constitutes saliva. The 
 paroted gland contains only serous albumin- 
 oid cells, the mucous cells being conspicuously 
 absent from this salivary organ. 
 
 The essential elements in the secretion of 
 saliva are, as in all glands, the epithelial cells; 
 but from the fact that healthy saliva contains 
 no morphological elements, it may be asserted 
 that neither the mucous nor the serous cells 
 of the salivary glands contribute more than 
 their contents to the formation of saliva. It 
 is not probable that physiologically the cells 
 of these glands are destroyed in the process 
 of secreting saliva, but rather, that they 
 elaborate their peculiar contents, and then 
 enter into a state that favors the discharge of 
 this elaboration, without the disintegration of 
 the cell body. 
 
 The regeneration of salivary glandular 
 epithelium is a less active process, than 
 the regeneration of the epithelial cells 
 
EPITHELIUM OF THE MOUTH 25 
 
 that form a part of the secretion of other 
 glands, is known to be. In health, therefore, 
 the morphology of the salivary cells is more 
 accurately described as a multiplication than 
 as a regeneration, the latter term conveying an 
 impression of cellular loss that does not belong- 
 to the secretion of saliva. This fact has an 
 important bearing upon the etiology of 
 epithelioma, aud will be discussed in its 
 appropriate place. 
 
 The multiplication of salivary cells proba- 
 bly takes place through almost the entire 
 length of the salivary tubes, and the alveoli 
 of the acinous gland. The process is believed 
 to be associated with the varicose fibrils of the 
 columnar cells that lie in contact with the 
 membrana propria, into which they project, 
 and form alveolar like groups. At least in 
 some instances, the proliferation of salivary 
 epithelium, is accomplished independently 
 of the nucleus of the columnar cells, for the 
 nucleus that appears in the new cell seems to 
 originate in the cell itself, by a process of free 
 cell formation, and not by a division of the 
 nucleus of the previously existing morx3ho- 
 logical element. 
 
 Passing in review this brief description 
 
26 EPITHELIUM OF THE MOUTH 
 
 of epithelium, and of epithelium of 
 the mouth, we find that epithelial cells, 
 especially those that invest the mucous 
 membranes, perform the function of secretion, 
 and that the arrangement of these cells into 
 alveoli, is not. for the purpose of changing 
 their function, but to facilitate and increase 
 their powers of functional activity. 
 
 It has further been observed that the life cy- 
 cle of epithelial cells is quickly completed, and 
 ends with the casting off of the cell from the 
 surface upon which it is developed ; that in 
 many instances, though probably not forming 
 an essential part of secretion, the cell, either 
 as a broken down body, or with its unity 
 undisturbed, is a constant element in 
 the secreted fluid ; its presence, however, is 
 frequently indicative of a pathological state. 
 
 It has also been observed that the epithelial 
 cells of the salivary glands are capable of 
 undergoing a process of free cell formation ; 
 that the nucleus, which is generally credited 
 with a controlling influence over cell division, 
 is in this instance, powerless to impart to 
 the progeny of the columnar cell, the physio- 
 logical function, for which it, the cell, exists ; 
 and that, therefore, though the cells so formed 
 
EPITHELIUM OF THE MOUTH 
 
 27 
 
 may follow a perfectly normal course, their 
 genesis renders it possible for them to do 
 otherwise. 
 
CHAPTER II. 
 Epithelioma of the Mouth. 
 
 It is characteristic of epithelial neoplasms 
 wherever developed, that they resemble in 
 the arrangement of their component parts — 
 connective tissue and epithelial cells — to a 
 greater or less degree, glandular tissue. This 
 likeness may in some instances, for example 
 in adenoma, be so striking as to give the im- 
 pression of a duplicate gland ; and in other 
 instances, for example in carcinoma, so 
 remote as to present, only in isolated parts, 
 the general features of secreting tissue — a 
 vascular basement membrane of connection 
 tissue, upon which is spread an investment 
 of non- vascular epithelial tissue. 
 
 To epithelial neoplasms, and by this is 
 understood epithelial tissue that is abnormal 
 in genesis, arrangement and function, may 
 be attributed a clinical history of the most 
 marked malignancy ; a malignancy that seems 
 to be in inverse ratio to the resemblance that 
 the new growth bears to glandular tissue. 
 
 In seeking the cause of this incompat 
 
30 EPITHELIOMA OF THE MOUTH 
 
 ibility with the life of an organism, it is not 
 satisfactory to attribute the entire sum of 
 malignancy to the simple multiplication of 
 epithelial cells, either as a primary growth, 
 or as a secondary deposit ; neither can so 
 much virulence be made to depend upon the 
 dissemination through the system of a 
 hypothetical poison that is manufactured in 
 a particular cell area — the epithelial neo- 
 plasm. But if to this variety of the tumor 
 disease, we apply the principles of rational 
 pathology ; of a pathology that has its 
 genesis in physiology, and that finds in 
 normal operations, the prototype of 
 abnormal operations, though still having 
 much to explain, we establish our investiga- 
 tions upon ascertained laws, and will learn 
 that as all vital phenomena are related, and 
 because in every instance health must proceed 
 disease, life antedate death, the malignancy 
 that accompanies a particular histogenesis, 
 is the result, either of an increase or a 
 decrease of the function of the part or tissue 
 effected, and not dependent upon a super- 
 added vital process. 
 
 An examination of the function of 
 epithelial cells, furnishes an insight 
 
EPITHELIOMA OF THE MOUTH 31 
 
 into at least one of the causes of their 
 marked malignancy when their function is 
 perverted. Thus, the office of epithelial cells, 
 especially the columnar investing epithelium 
 of the mucous membrane, and of the secreting 
 glands, is to extract from the blood a 
 peculiar pabulum. 
 
 In certain proportions this pabulum is 
 physiological in the blood, but if it falls 
 below, or rises above the limits of a normal 
 quantity, it is evident that we have to deal 
 with a more or less pernicious alteration of 
 the nutrient fluid. Now if by the numerical 
 increase of epithelial cells — a constant con- 
 dition of the growth of epithelioma — the 
 functional activity of that particular cell 
 area is augmented, either the blood is 
 deprived of some of its constituents, or some 
 manufacturing organ is called upon to main- 
 tain its normal standard. Is there not in 
 this found an explanation of the cachexy 
 that follows the development of epithelioma; 
 of the malnutrition, and wasting of tissues 
 that do not appear until the epithelial cells, 
 the gland cells, have multiplied beyond their 
 normal number ; until the function of second- 
 arily effected glands, as when the lymphatics 
 
32 EPITHELIOMA OF THE MOUTH 
 
 become implicated, is so altered as to 
 convert the lymphatic gland into one that 
 resembles the organ primarily diseased. 
 
 But this is not the only effect of the 
 multiplication of epithelial cells, for it 
 becomes evident that these cells, while they 
 appropriate more pabulum than should be 
 removed from the blood, are also capable, by 
 virtue of their glandular endowment, of 
 originating an entirely new and abnormal 
 secreting function, the performance of which 
 not only represents a process of removing 
 from the blood elements that form a part of 
 its normal composition, but also a manufac- 
 turing process, by which the elements 
 secreted by the abnormal glands cells, are 
 by them elaborated and returned to the sys- 
 tem in a condition, harmful, if not poisonous. 
 In this sense a neoplasm may be said to owe 
 its malignancy to a peculiar poison, but the 
 possibility of such a poison is one of the 
 closing features of a series of phenomena, 
 that if they are not sufficient to cause the 
 distraction of the organism, certainly reduce 
 vitality to such a degree, as to render the 
 system unable to resist even slightly adverse 
 conditions. 
 
EPITHELIOMA OF THE MOUTH 33 
 
 Epithelioma of the month has its origin in 
 the epithelial cells, either of the mucous 
 membrane, the mucous glands, or the salivary 
 glands. 
 
 Two distinct initial processes are observed 
 in the development of epithelioma of the oral 
 mucous membrane. The more highly malig- 
 nant form, first appears in the substance of the 
 investing membrane, as a nodule of epithelial 
 cells. From the centre of this nodule the 
 ulceration proceeds outwards, the more 
 superficial layers of tissue being gradually 
 involved in the process of destruction. The 
 extension of the nodular variety of epithelio- 
 ma is not confined to the superficial tissues, 
 but is essentially an infiltrating growth that 
 involves contiguous structures. 
 
 From the primary nodule, processes com- 
 posed of the same epithelial .cells, project 
 into the sub-mucosa, until finally this struc- 
 ture is occupied in every direction by the 
 same carcinomatous mass. The neoplasm is 
 further enlarged by separate nodules uniting. 
 These deeper parts may join in the ulceration 
 process, and then give rise to excavations in 
 the centre of the epithelioma, from which 
 may sometimes be pressed a yellowish, 
 
34 EPITHELIOMA OF THE MOUTH 
 
 cheesy mass, composed of broken down 
 epithelial cells, and cells that have passed 
 into a state of fatty degeneration. 
 
 All of the carcinomatous tissue is not 
 included in the destructive process of ulcer- 
 ation, but there constantly exists a shell of 
 >epitnelial cells, hard and closely packed, 
 more or less supported ux^on a stroma of 
 connective tissue, which forms the indurated 
 base so characteristic of epithelioma. The 
 stroma upon which the outer zone of carcinoma 
 cells rests, and that supports the collections 
 of epithelial cells that occupy the parenchyma 
 of the neoplasm, is sometimes embryonic, 
 partaking of a sarcomatous character. Such 
 a mixed histology marks a superlative degree 
 of malignancy. 
 
 The ulceration of an epithelioma shows no 
 disposition to develop cicatricial tissue, even 
 though a temporary scab is formed. Neither 
 is there observed the contraction that consti- 
 tutes a feature of other ulcerations, the entire 
 process is one of the destruction of existing 
 tissues, without reconstruction ; of the sub- 
 stitution of erratic for normal morphology. 
 
 The other and more benign variety of 
 epithelioma of the mucous membrane of the 
 
EPITHELIOMA OF THE MOUTH 35 
 
 mouth, begins on the surface of the epithelial 
 layer, as a crack, or at first, as a simple 
 abrasion, that later ulcerates, the ulceration 
 extending superficially and never involving 
 the deeper structures. Sometimes a small 
 soft wart, is the first lesion observed ; but 
 probably that condition is generally, if not 
 always, preceded by a slight fissure, the 
 irritation of which is sufficient to cause such 
 a proliferation of epithelial cells, as would 
 form a condyloma. 
 
 The initial lesion, from its apparent 
 insignificance, is easily overlooked by both 
 patient and surgeon. 
 
 Excepting for the depth of tissue involved, 
 the two varieties of mucous epithelioma of 
 the mouth are with difficulty distinguished, 
 after ulceration has become well developed. 
 There is the same zone of induration sur- 
 rounding both processes ; the same spread- 
 ing ulcer ; the same healthy tissue beyond 
 the sharply defined, hardened border, and 
 the same enlargement of the lymphatic and 
 salivary glands. The diagnosis will rest 
 principally on the early history of the case, 
 and on the degree of rapidity with which 
 it reaches a fatal termination. 
 
36 EPITHELIOMA OF THE MOUTH 
 
 Any of the minute tubular glands of the 
 mucous membrane of the mouth may be the 
 seat of epithelioma, and it seems probable, 
 that occasionally the nodular variety of 
 mucous epithelioma arises in these structures. 
 
 By a process of proliferation, the secreting 
 cells soon occupy the interior of the gland 
 and its excretory duct, converting the organ 
 into a solid mass of epithelial cells. The 
 morbid process being communicated to the 
 superficial epithelium by means of the open- 
 ing of the gland, or a ''catalytic action" 
 taking place, ulceration follows as in the 
 nodular variet}^ of mucous epithelioma. 
 Epithelioma of the mucous glands possesses 
 marked malignancy ; and it is apparent that 
 the situation of the invaded organ, in the loose 
 connective tissue, offers peculiar advantages 
 for the infiltration of contiguous structures. 
 
 Epithelioma of the salivary glands begins 
 as a proliferation of the columnar epithelium 
 of an isolated nodule. Other parts of the 
 gland are soon involved, and the process 
 spreading outwards, both deep and super- 
 ficial ulceration supervenes. The rjrocess of 
 destruction, however, generally belongs to 
 the later stages of the disease. 
 
EPITHELIOMA OF THE MOUTH 37 
 
 The tumor is at no time well defined from 
 the connective tissue in which the salivary 
 gland lies ; and the stroma of the neoplasm 
 becomes either embryonic, or, from inflam- 
 mation excited by the epithelial cells, entirely 
 disappears, as the neoplastic process pro- 
 gresses. 
 
 It is, therefore, not unusual for epitheli- 
 oma of the salivary glands to present a mixed 
 histology. The connective tissue stroma 
 may be replaced by sarcomatous tissue, which 
 becomes incorporated into the tumor, form- 
 ing a net- work between the groups of epithe- 
 lial cells. As with the epithelioma of the 
 mucous glands that show this mixed minute 
 anatomy, the salivary epitheliomata are 
 highly malignant. 
 
 It is also observed, agreeable to the two 
 sets of cells found in the salivary glands, 
 that mucoid elements may be mingled with 
 the characteristic epithelial cells of the 
 neoplasm. This arrangement has not been 
 seen in epithelioma of the parotid gland, 
 because of the absence of mucoid cells from 
 that organ. 
 
 The minute anatomy of epithelioma of the 
 mouth, shows in every direction, the distin- 
 
38 EPITHELIOMA OF THE MOUTH 
 
 guishing features of pavement epithelioma 
 generally. 
 
 To the naked eye the tumor presents a 
 grey or rose tinted appearance. On section, 
 the mass is found to be of unequal consist- 
 ence, and to be made up of dense collections 
 of epithelial cells, arranged in concentric 
 layers that resemble the leavf s of an onion. 
 Between these bird-nest bodies a less dense 
 connective tissue stroma lies, that may 
 exhibit in different parts almost any degree 
 of development. In this stroma, the arteries, 
 veins and capillaries pass, but are never 
 continued into the epithelial tissue. 
 
 It will thus be seen that there is little in 
 the individual cells of epithelioma when 
 isolated, to determine the nature of their 
 genesis. Normal epithelial cells, when func- 
 tionally active, or when subjected to pres- 
 sure, assume various shapes : it is, therefore, 
 the arrangement of these elements that must 
 be looked upon as bearing a principal part 
 in the neoplasm ; and their relation to the 
 connective tissue, that anatomically distin- 
 guishes epithelial, from connective tissue 
 neoplasms. 
 
 If the section of the abnormally proliferat- 
 
EPITHELIOMA OE THE MOUTH 39 
 
 ing epithelium is made to extend through 
 the matrix of the growth, it will be found 
 that there is no absolute dividing line between 
 the tissues, save in their arrangement, and 
 that this peculiar arrangement of epithelial 
 and connective tissue, becomes less marked 
 towards the periphery of the mass, passing 
 by imperceptible gradation, into healthy 
 tissue. 
 
 The absence of a limiting membrane to 
 epithelial neoplasms, is the chief cause of 
 their invasion of neighboring structures, and 
 of the infection of lymphatic glands. 
 
 Though, as we have seen, any part of the 
 epithelial lining of the mouth may become 
 the starting point of epithelioma, this neo- 
 plastic disease shows a preference for certain 
 locations, to the almost entire exclusion of 
 others. 
 
 As a primary disease, epithelioma of the 
 mouth is rarely developed in other locations 
 than the lips, the gums, the salivary glands, 
 the tongue, and the palate. The tonsil? 
 the cheeks, and the floor of the 
 mouth, are generally attacked secondarily, 
 or by direct continuity of tissue. 
 
 The reasons for the immunity enjoyed by 
 
40 EPITHELIOMA OF THE MOUTH 
 
 some parts of the mouth, and the susceptibility 
 shown by others, is not always discoverable. 
 If we receive mechanical or chemical injuries 
 as etiological factors, and we certainly are 
 not justified in excluding either, there is 
 found a class of exciting causes of epithelioma 
 of the lips, gums, and anterior part of 
 the tongue ; but the entire mouth is subject 
 to much the same kind and degree of trauma, 
 with the different results named ; there must, 
 therefore, be other etiological factors, that 
 either alone or in conjunction with traumatic 
 causes, are powerful to excite a local neo- 
 plastic process. I am inclined to believe 
 that the principal factor in the etiology of 
 epithelioma of the mouth, will be found to 
 relate to the peculiar kind and degree of 
 functional activity of the minute mucous 
 glands situated in the region affected. The 
 theory that epithelioma owes its origin 
 to a perverted glandular function — not neces- 
 sarily of a secreting organ, but generally so, 
 because there the glandular function is 
 intensified — has elsewhere been referred to, 
 and there is no reason for excluding the 
 present variety of epithelioma from that 
 hypothesis. 
 
EPITHELIOMA OF THE MOUTH 41 
 
 The labial glands, for example, are much 
 more abundant in the lower than in the 
 upper lip, and are generally entirely absent 
 from the angles of the mouth. ]N"ow it is 
 exactly where the labial glands are the most 
 plentifully developed, at the junction of the 
 mucous membrane with the skin, and on the 
 free border of the lower lip between the 
 median line and the angle of the mouth, that 
 epithelioma of the lip is usually developed. 
 1 do not remember to have seen any cases 
 reported in Avhich the neoplastic process 
 began in the angle of the lips, nor have I 
 met with such examples in my own practice. 
 In the upper lip epithelioma is so rare, that 
 its existence has been denied. 
 
 The lingual glands are distributed at the 
 root of the tongue, on the sides and at its 
 apex, and it is in these situations that epi- 
 thelioma is most frequently developed. The 
 same relation is found between epithelioma 
 and the glands of the palate and uvula ; in 
 the latter part the mucous glands are very 
 large. 
 
 An exception to the glandular origin of 
 oral epithelioma may seem to exist, when 
 this neoplasm is developed from the gums ; 
 
42 EPITHELIOMA OF THE MOUTH 
 
 but upon investigation, we find that columnar 
 epithelial cells are largely concerned in the 
 construction of the investing epithelium of 
 the gums and alveoli, and we have already 
 observed that columnar cells are in a peculiar 
 manner capable of assuming the function of 
 mucous glands. 
 
 While, therefore, columnar epithelial cells 
 form a part of the oral mucous membrane 
 generally, it is probable that the etiological 
 factor of mechanical irritation, enters with 
 force in the localization in the gums, of 
 epithelioma. For here irritation is very 
 likely to arise from a decayed or ragged 
 tooth, and from the presence between and 
 around the teeth of decomposed food, or to 
 follow the attempt to remove such collections 
 of effete matter. 
 
 It is possible that derangement of the 
 digestive organs may exert some influence 
 over the development of oral epithelioma, 
 though the degree of this influence cannot 
 be told. Cases however occur, in which 
 chronic gastritis and dyspepsia rjrecede the 
 development of epithelioma of the mouth. 
 If these circumstances stand in the relation 
 of cause and effect to each other, it is rjrob- 
 
EPITHELIOMA OF THE MOUTH 43 
 
 able that the oral epithelium is excited, or 
 possibly only irritated — the initial lesion — 
 by the long-continued acid of effete matter 
 or other risings from the stomach. 
 
 The clinical history of epithelioma shows 
 the development of this neoplasm to be 
 associated with the period of physical decay; 
 to the time of life when the organism as a 
 unit, and in its individual parts, is beginning* 
 to disintegrate, beginning to offer less resist- 
 ance to its environment, and to -enter upon 
 that process of equilibration, that in its per- 
 fection results in dissolution, and the re- 
 establishment of organisms. 
 
 I have elsewhere (A Treatise on the Breast 
 and its Surgical Diseases) referred to the 
 probable connection between the upfolding 
 of the mammary glandular function, and the 
 development of epithelioma ; the same rela- 
 tion probably exists between the involution 
 of all epithelial structures and their path- 
 ology. 
 
 The mammary gland being x3hysiologically 
 subject to oft repeated periods of evolution 
 and involution, may naturally be expected 
 to illustrate this hypothesis in a marked 
 degree ; but the transitory nature of epithe- 
 
44 EPITHELIOMA OE THE MOUTH 
 
 Hum generally, at once suggests that a similar 
 relation may obtain between epithelial neo- 
 plasms wherever developed, and the meta- 
 morphoses that accompany the natural death 
 and desquamation of all epithelial bodies. 
 
 It is thus shown to be the age of the 
 individual unit rather than the aggregation 
 of units — unless these bear a definite relation 
 to each other — that determines the develop>- 
 ment of epithelioma generally, and therefore, 
 of the mouth. It is however true, that 
 physiologically, all secreting organs, even 
 those that, unlike the mammary gland and 
 ovaries are not subject to a final complete 
 involution, become less active with advancing 
 years ; and that the secreting cells — the 
 epithelial cells — pass into a condition of fatty 
 degeneration and vacuolation during the 
 process of upfolding, and as their function 
 becomes less vigorous. 
 
 The glands that enter actively into the 
 process of digestion, are notably effected by 
 the senile period. The salivary glands be- 
 come less active, and may continue at a very 
 low degree of functional activity for a length 
 of time ; this same imperfect glandular oper- 
 ation, is prolific of neoplastic processes, par- 
 
EPITHELIOMA OF THE MOUTH 45 
 
 ticularly of epithelioma. Many of the gland 
 cells become at the folding np process, or low 
 degree of functional activity, waste cells, 
 bodies intended to be thrown off from the 
 system, but if these are not removed from 
 the gland, a circumstance that frequently 
 occurs, being endowed with epithelial powers 
 of regeneration, perverted, however, they 
 form a center for pathological cell prolifera- 
 tion. In this sense, epithelioma of the mouth, 
 is a disease of declining years, because to 
 declining years belong certain histological 
 changes that per se favor the development 
 of this neoplastic disease. 
 
 But it is evident, that no period can be 
 named, during which epithelioma must de- 
 velop ; for individuals differ, as much in the 
 rapidity with which they pass through their 
 several stages toward maturity, and then re- 
 verse the process, as they do in physiognomy, 
 or mental qualities ; and while it is still true 
 that epithelioma is a disease of decay one 
 organism may mature, be maintained, and 
 decline, in a much shorter period than is 
 consumed by another organism. I am there- 
 fore inclined to regard the development of 
 epithelioma in adolescence, as indicating a 
 
46 EPITHELIOMA OF THE MOUTH 
 
 premature general or local decay ; a folding 
 up of some process, before its natural time 
 of involution. 
 
 With a better understanding of the genesis, 
 histology, and chemical history of epithelio- 
 ma, it becomes more evident that the disease 
 in its first stages, is a purely local disorder, 
 and not, as formerly believed, and still held 
 by a few eminent surgeons, the out-growth 
 of a constitutional state. 
 
 As a proof of the local origin of epithelio- 
 ma, it is only necessary to remember that the 
 neoplasm appears, — is indeed, usually dis- 
 covered quite by accident — , in jDersons who 
 enjoy excellent health. Before the neoplasm 
 is observed, there are no indications of the 
 approach of the future disease, and it is not 
 until after the development of the local mal- 
 ady, and the development of secondary neo- 
 plasms, that the system suffers ; that the 
 peculiar cachectic appearance that belongs 
 to epithelioma, makes itself manifest. The 
 involvement of the system, in some instances 
 follows so rapidly upon the development of 
 the primary neoplasm, as to lead to the im- 
 pression that the general disease preceded 
 the local, but if such cases are examined care- 
 
EPITHELIOMA OF THE MOUTH 47 
 
 fully, and their previous history analyzed, it 
 will be found otherwise. 
 
 The results of the removal of an epithelio- 
 ma in its earliest recognizable stage, also 
 speaks in favor of a local origin ; for the 
 neoplasm will not return, if the operation is 
 performed before secondary nodules develop ; 
 and prior to the lymphatics being involved 
 in the morbid process. 
 
 The constitutional origin of epithelio- 
 ma,— all that is here said of epithelioma 
 generally, applies to epithelioma of the 
 mouth with equal force — , and the necessary 
 inheritance and transmission of the neo- 
 plastic disease, are closely related theories, 
 and must fall together. 
 
 That epithelioma, or auy other peculiar 
 and pathological histo-genesis, to which an 
 organism has become so far accustomed, as 
 to tolerate its existence, may be transmitted 
 to an offspring, in the same manner in which 
 a characteristic feature or entirely physio- 
 logical distinction are given, admits of no 
 question ; but that such a genesis is essential 
 to the development of a pathological condi- 
 tion, any more than it would be to a physio- 
 logical condition, does not appear, from what 
 is known of biology. 
 
48 EPITHELIOMA OF THE MOUTH 
 
 The son may resemble his ancestors' phys- 
 iology, and pathology, or he may not, the 
 determining factor in either case, being un- 
 known. Or again, the child may present 
 peculiarities of structure, physical or moral 
 deformities, that cannot be traced to any 
 progenitor. 
 
 There is no reason for excluding such 
 phenomena from the realm of the redistrib- 
 ution, and rearrangement of force and mat- 
 ter, in which vital changes constantly have 
 their origin. In this domain, belongs the 
 variation that makes the individual ; that 
 makes the son, though an outgrowth of his 
 father, differ from him. 
 
 While therefore a pathological histogene- 
 sis may be transmitted from parent to off- 
 spring, its appearance in the child, does not 
 involve a belief in heredity, nor does it 
 contradict, the de noro origin of the change. 
 
 The etiology, as well as the pathology of 
 epithelioma will become clearer, the more 
 our investigations are directed towards normal 
 methods, as the prototype of abnormal meth- 
 ods ;the closer we acknowledge to be the rela- 
 tionship between health and disease. We 
 will then see that one, is the continuation of 
 
EPITHELIOMA OF THE LIP 49 
 
 the other ; that both processes are vital phe- 
 nomena, and subject to the same laws ; that 
 in health there is a general gradual establish- 
 ing of an equilibrium between the organism 
 and its environment ; that in disease there is 
 in isolated parts, a premature like result, 
 that finds its motive power in an increase or 
 decrease, of functional activity. 
 
 Epithelioma oftlielij?^ begins as a small, 
 hard, painful nodule, situated immediately 
 beneath the superficial layer olepithelium, at 
 the junction of mucous membrane and skin. 
 The neoplasm therefore has its rise in the 
 columnar cells that cover the papilla, or as 
 has already been suggested, in the epithelium 
 ofthe labial glands. 
 
 Tin:; primary nodule increases in size by a 
 more or less rapid proliferation of the epithe- 
 lial cells, and soon sends processes into the 
 underlying connective tissue. As the de v eper 
 structures become involved, ulceration always 
 takes place. At first the destruction of tissue 
 is superficial,but the process soon spreads, and 
 a deep, uneven, granulating excavating is de- 
 veloped, over which is formed a constantly 
 renewed blackish gray scab. The edges of 
 the ulcer are somewhat overhanging, and 
 
50 EPITHELIOMA OF THE MOUTH 
 
 present the hard, almost cartilaginous con- 
 sistence, that characterizes all epithelioma- 
 tous ulcers. 
 
 The destruction caused by epithelioma of 
 the lip, is principally in the direction of the 
 superficial structure, or more strictly, the 
 ulceration of both deep and superficial 
 tissues, proceeds together. 
 
 In the earlier stages of the neoplasm, the 
 abnormal histogenesis is confined to the 
 epithelial tissue, but as this becomes more 
 removed from healthy growth, the neighbor- 
 ing connective tissue cells are excited to pro- 
 liferate, and there ensues an area of embry- 
 onal connective tissue cells, that surrounds 
 the epithelial nodule. 
 
 Epithelioma of the lip, is not to be ranked 
 among the rapidly developing forms of this 
 neoplasm. Its first stages are rather slow, 
 and are not clearly defined. The enlarge- 
 ment of the sub-maxillary and cervical 
 glands, does not occur until the primary 
 nodule has become well devekrped, and the 
 diagnosis may be obscured by the superficial 
 scab, which not being removed, jn'events a 
 knowledge of the extent of the underlying 
 destructive ulceration. 
 
EPITHELIOMA OF THE LIP 51 
 
 The disease with which epithelioma of the 
 lip, is most likely to be confounded, is the 
 primary lesion of syphilis, the occurrence 
 of which in the mouth, there is reason to 
 believe is increasing in frequency in this 
 country. The history of the case, wiU how- 
 ever generally prove sufficient for a diagno- 
 sis, when a not very well defined case is 
 rendered more obscure, by denying the possi- 
 bility of infection. 
 
 Epithelioma of the lip, is a disease of ad- 
 vancing life ; chancre is generally found in 
 youth. 
 
 Epithelioma of the li|3, is almost confined 
 to the lower lip ; chancre is confined to no 
 locality. 
 
 Epithelioma of the lip is usually developed 
 in men ; chancre of the lip is usually found 
 in women. 
 
 The glands in epithelioma of the lip, are 
 not involved until quite late in the disease ; 
 in chancre of the lip, they begin to enlarge 
 before the second month of the disease. 
 
 The ulcer of epithelioma of the lip, has a 
 Hat bottom, with overhanging, clearly, de- 
 fined edges ; the ulcerated chancre is more 
 of an excoriation, and when the tissue is lost, 
 
52 EPITHELIOMA OF THE MOUTH 
 
 the excavation is funnel shaped, the edges 
 shelving to the base of the ulcer. 
 
 The scab is a constant feature of epithel- 
 ioma of the lip, and its characteristic appear- 
 ance has been described ; chancre of the lip 
 does not always form a scab, and when the 
 process takes place, it is imperfect, the cov- 
 ering of the sore being thin, and easily 
 removed. 
 
 Epithelioma of the lip, is usually attended 
 with severe burning pain : chancre of the lip, 
 as in other situations, causes little, if any 
 suffering. 
 
 The two diseases can be further differenti- 
 ated by applying the test of the microscope. 
 In one case is found the characteristic ar- 
 rangement of non-vascular epithelial cells. 
 and vascular connective tissue, the epithelial 
 cells occupying the histological position of be- 
 ing the primarily effected bodies ; in the other 
 case, epithelial tissue occupies a most sub- 
 ordinate position, the lesion consisting almost 
 entirely of embryonal connective tissue, in 
 which the vessels are large, and numerous. 
 The microscope also shows the discharge from 
 epithelioma to be made up of broken down 
 epithelial cells, and the discharge from a 
 
EPITHELIOMA OF THE LIP 53 
 
 chancre, to consist of pus corpuscles, blood 
 and serum. 
 
 Epithelioma of the lip, sometimes closely 
 resembles a lupus ulcer, or lupus exedens, 
 but the history and pathology of the two 
 diseases are entirely dissimilar, and when 
 examined, will be sufficient to establish a 
 diagnosis. 
 
 Epithelioma belongs to late life ; lupus to 
 youth, being rare after the thirty-fifth year, 
 and most frequent about the sixteenth year. 
 
 Epithelioma of the lip is more frequent in 
 men ; lupus is more frequent is women. 
 
 Epithelioma is rare in the upper lip ; lupus 
 is rare in the lower lip. 
 
 The border of epithelioma has been de- 
 scribed ; the border of lupus is not generally 
 infiltrated, nor are the lymphatic glands 
 enlarged. 
 
 Examination shows the corium to be the 
 seat of lupus ; the neoplasm is therefore of 
 connective tissue genesis, any epithelial cells 
 that are found may be considered as quite 
 accidental to the disease. 
 
 The ulceration that accompanies epitheli- 
 oma of the lip, may be so extensive as to 
 destroy the labial muscles ; and the patho* 
 
54 EPITHELIOMA OF THE MOUTH 
 
 logical action set up so powerful, as to pro- 
 duce most serious nutritive change, in the 
 maxillary bones. 
 
 The etiology of epithelioma of the lip, is 
 believed to include the local irritation caused 
 by the use of a pipe. It is very true that 
 many persons who use tobacco in this way, 
 suffer from ejjithelioma, but on the other 
 hand many do not, for the disease is very 
 rare in the East, where both men and women 
 smoke pipes. I am inclined to think, that if 
 smoking has any value, considered as a cause 
 of epithelioma, it is the heat of the pipe stem, 
 that produces local irritation. In eastern 
 countries, the mouth-piece used, is removed 
 some distance from the part of the hookah 
 that contains the tobacco, and does not become 
 at all heated ; to this circumstance, we may 
 possibly attribute the immunity from epithel- 
 ioma of the lip, that is enjoyed by Orientals. 
 
 Epithelioma of the lip, however, occurs in 
 men who do not smoke a pipe, or use tobacco 
 in any form, this therefore can be regarded 
 as but one of the causes of the disease ; other 
 causes may be any irritant, that acting upon 
 the labial glands, or mucous membrane, ex- 
 cites their epithelium to proliferate, or the 
 
EPITHELIOMA OF THE LIP 55 
 
 same result may follow a purely local over 
 nutrition of the parts. 
 
 The average duration of life of persons 
 suffering with epithelioma of the lip, if the 
 disease is allowed to progress unmolested, is 
 about eighteen months, but in no form of 
 epithelioma, may a cure more reasonably be 
 expected to follow operative treatment, than 
 the one now under consideration, it must 
 however be understood, that such favorable 
 results can be obtained, only when the oper- 
 ation is performed in the early development 
 of the neoplasm, while it is still a local cell 
 derangement. If treatment is delayed until 
 secondary nodules develop, and the sub- 
 maxillary glands are participating in the 
 morbid process, no operation of lesser mag- 
 nitude than to include all the diseased tissues, 
 will avail to arrest the progress of the malady; 
 it is obvious that such an operation would 
 be impracticable, therefore any treatment 
 that may be adopted, after the infiltration of 
 tissues has begun, must be palliative. Remov- 
 al of the primary nodule may be considered 
 advisable even at a late day, but the disease 
 is thereby, only arrested, and one centre of 
 infection destroyed. In a few months, or 
 
56 EPITHELIOMA OF THE MOUTH 
 
 before the cicatricle tissue has formed, the 
 neoplasm will develop either in the neigh- 
 boring glands, or at the seat of the primary 
 tumor. There is reason to believe that con- 
 siderable infiltration from the local neoplasm 
 into the lymphatic glands, sometimes takes 
 place before these glands show any sign of 
 disease ; the absorbed epithelial cells remain- 
 ing inactive, until conditions favorable to 
 their proliferation obtain. It may thus 
 occur, that after the removal of an epitheli- 
 oma of the lip that was considered a local 
 disease, the cervical glands soon develop the 
 same morbid histogenesis ; such a result may 
 be looked npon as proof of early cell infil- 
 tration, and may be received in favor of a 
 timely operation. 
 
 Thus far, I have spoken entirely in favor 
 of the knife, in the treatment of epithelioma 
 of the lip, because I believe it to be the most 
 certain means of curing this particular form 
 of epithelioma, when the treatment can be 
 commenced early in the course of the disease. 
 
 Prom the use of caustics, or any other 
 treatment, applied for the purpose of de- 
 stroying the neoplastic cells, I have never, 
 in a case that I would be willing to pronounce 
 
EPITHELIOMA OF THE LIP 57 
 
 epithelioma, witnessed a cure. I am aware 
 that other surgeons, whose opinion commands 
 respect, report better results than I have 
 seen, or obtained, from the use of such con- 
 servative methods. I may have been unfor- 
 tunate in the selection of my cases. 
 
 Aside from the clinical results, I cannot 
 but look upon the principle of treatment as 
 unscientific, when a more rapid, and certain 
 method exists in the knife. It is acknowl- 
 edged that the disease must be removed ; to 
 accomplish this with an escharotic, requires 
 many applications, and necessarily consumes 
 valuable time. A constant feature of the 
 treatment, is a certain degree of inflamma- 
 tion in the neoplasm and its matrix, a path- 
 ological condition, that by rendering absorp- 
 tion more active, is calculated to defeat the 
 object of the treatment. 
 
 If in the surgeons judgment a. part must 
 be removed, let the operation be performed 
 as speedily as the safety of the patient, and 
 thoroughness, will permit ; always remem- 
 bering that a make-shift cannot occupy a 
 place in the scientific surgeons equipment. 
 
 With the use of toxical applications of 
 medicinal substances, I have not had much 
 
5S EPITHELIOMA OF THE MOUTH 
 
 experience. Hydrastis, in the form of the 
 powdered root, made into a poultice, com- 
 bined with the internal use of the triturated 
 drug, is highly recommended. Phytolacca, 
 applied after the same method, is also well 
 spoken of. Conium. locally and internally, 
 has in my hands greatly relieved the pain 
 of epithelioma of the lip, but I have come to 
 rely chiefly on the Iodide of Calcarea, to mit- 
 igate the suffering in these cases. Antim- 
 erud, Arsenic, Clematis, Asafcetida, and 
 Ranunc-bulb, may be found indicated. Es- 
 pecially the latter remedy, used locally and 
 internally, seems to have effected some cures 
 of labial epithelioma. 
 
 The operation for the removal of an epith- 
 elioma of the lip, is very simple. 
 
 When a general anaesthetic is used, I 
 prefer chloroform, which if carefully admin- 
 istered, — the respiration should be observed, 
 not the pulse, — need not complicate the 
 danger of the operation. Sufficient local 
 insensibility however can be induced, with 
 the Hydro chlorate Cocoaine. 
 
 An assistant compresses one side of the 
 lip between his thumb and index finger, 
 beyond the line of the proposed incision^ 
 
EPITHELIOMA OF THE LIP 59 
 
 while the surgeon compresses the opposite 
 side, for the double purpose of controling 
 the labial arteries, and of steadying the lip 
 while lie transfixes it below the tumor. By 
 cutting towards the free border of the lip, 
 the first incision is made. Entering the 
 knife at the point of transfixion, the second 
 incision is accomplished by again cutting 
 towards the free border of the lip, in such a 
 direction as to include the tumor in a Y 
 shaped mass of tissue. The knife should in 
 no instance touch the neoplasm, but should 
 constantly be made to cut through healthy 
 structures. 
 
 The hemorrhage, which is sometimes quite 
 profusf when compression of the lip is re- 
 moved, is generally control ed by bringing 
 the cut surfaces together. 
 
 Before closing the wound, it is well to 
 wash the edges of the flaps with a solution of 
 the chloride of zinc, to destroy any wander- 
 ing infectious epithelial cells, that may 
 remain. 
 
 For the purpose of holding the flaps in 
 contact, I prefer to use one pin at the ver- 
 milion border of the lip, and many silver 
 sutures in the remaining part of the wound. 
 
60 EPITHELIOMA OF THE MOUTH 
 
 Much care is required to maintain the line of 
 the lip, and it is to better accomplish this 
 that I introduce the single pin, over which 
 silver wire that has been previously oiled, to 
 facilitate its removal, is wound in the form 
 of the figure eight. 
 
 The silver sutures should be passed through 
 the entire thickness of the lip, and if the 
 tension on the tissues is very great, they 
 should be reinforced with strips of adhesive 
 plaster. 
 
 The dressing of the wound consists of a 
 sublimated cotton compress, and a bandage 
 about the head and face. 
 
 At the end of the second or third day, the 
 wound should be examined, and if x^ossible, 
 the sutures removed, to avoid the scars that 
 may follow, if they are allowed to remain 
 too long. In all cases after removing the 
 sutures, adhesive plaster should be applied 
 for several days, until the union seems per- 
 fectly firm. 
 
 For use during the operation, and to 
 cleanse the sponges and hands of the surgeon 
 and his assistants, the bichloride of mercury, 
 1-1000, will be found very satisfactory. It 
 is a perfect antiseptic, and free from danger, 
 if used in this strength. 
 
EPITHELIOMA OF THE GUMS 61 
 
 Epithelioma oT the gums, is at first an 
 essentially superficial lesion. There is no 
 tumor, and no swelling of the effected parts, 
 until the disease is well advanced ; neither 
 does pain form a constant or marked feature 
 of the neoplasm. 
 
 The disease begins as an apparently simple 
 abrasion, a crack, of the investing epithelium 
 of the gums. The initial lesion may be situ- 
 ated at the border of the alveolus, or where 
 the mucous membrane is reflected upon itself 
 at the angle formed by the floor of the mouth 
 and the inferior maxilla, for epithelioma of 
 the gums as a primary disease, is most fre- 
 quently developed in the lower jaw. 
 
 From the slight, scarcely noticeable abra- 
 sion, there soon develops a ragged ulcer, 
 with the characteristic indurated border of 
 epithelioma. The ulcer, if beginning on the 
 inner side of the gum, spreads towards the 
 tongue, but if the abrasion has its seat on 
 the outer side, the cheek is soon involved ; 
 more rarely, the ulcer spreads across the gum, 
 to involve both tongue and cheek. 
 
 The destruction of tissue that begins in 
 epithelioma of the gums, is only limited by 
 the distribution of epithelial cells, and if not 
 
02 EPITHELIOMA OE THE MOUTH 
 
 arrested, the tongue, the palate, the pharynx, 
 the entire epithelial lining, may become im- 
 plicated, producing a vast ulcerated surface, 
 that interferes with deglutition, and renders 
 speech difficult, if not. impossible. The 
 almost cartilage like hardness of the floor of 
 the ulcer, causes great stiffness of the parts, 
 and the sharp burning pains, that increase as 
 the disease spreads, renders life a prolonged 
 misery. 
 
 The suffering is augmented by the quan- 
 tity and fetor of the discharge, which is 
 expectorated with such difficulty, that the 
 patients is soon exhausted ; and also by the 
 enlargement of the salivary, and cervical 
 lymphatic glands, which become very pain- 
 ful. 
 
 Histologically, it is impossible for the 
 maxillary bone to become converted into a 
 part of an epithelial neoplasm, for cellular 
 substitution does not extend beyond the 
 limits of a tissue series. Those cases of 
 epithelioma, in which the maxillary bones, 
 beyond the lining of the alveolar cavity 
 become diseased, or destroyed, are instances, 
 not of the connective tissue cells becoming 
 epithelial cells, but first, of the invasion of 
 
EPITHELIOMA OF THE GUMS 63 
 
 the bony structure by epithelial bodies, and 
 second, of the inflammatory new formation 
 of connective tissue cells, and the consequent 
 development of embryonal bodies. 
 
 The general diagnostic features of epithe- 
 lioma of the mucous membrane, will usually 
 serve to distinguish the disease from other 
 ulcerations of the gums, and investing epith- 
 elium of the mouth. The mature age of 
 the patient ; the hardness of the base of the 
 ulcer ; the implication of the absorbents ; 
 the characteristic pain, and the tendency of 
 the ulcer to spread rapidly in every direc- 
 tion, present a picture sufficiently clear to 
 form a diagnosis of epithelioma, but if doubt 
 remains, the microscope will determine the 
 nature of the disease. 
 
 A section of epithelioma, shows the char- 
 acteristic epithelial and connective tissue 
 arrangement, and that the discharge consists 
 of broken down epithelial cells ; a section of 
 any other variety of ulceration that is likely 
 to be confounded with epithelioma, shows 
 an absence of epithelial tissue, and that the 
 disease belongs to the connective tissue neo- 
 plasms. 
 
 The causes of epithelioma of the gums, 
 
04 EPITHELIOMA OE THE MOUTH 
 
 may usually be traced to some local irrita- 
 tion, or injury. A broken or ulcerated rooth. 
 or an injury to the gum induced by using a 
 stiff tooth-brush, or tooth-pick, are quire 
 sufficient to excite a local ej 
 
 . that may result in a neoplasm, if the 
 parts are in the stage of legeneration, that 
 
 ieds and nies the develop] 
 
 - epithelial 
 Epithelioma of the gums, and this is here 
 made to include all the = :ial epithelial 
 
 .tions. that originating in the gum. 
 involve more or less of the buccal mucous 
 : : very amenable to medical 
 treatment. 
 
 There are a few remedies however, that 
 administered internally, and applied locally, 
 — for I believe the latter emphasizes the 
 action of a di ig — . offer some hope, that the 
 
 se can be cured without the aid of the 
 knife. Foremost among these I would place 
 Ranunculus hvXbosus. The provings of the 
 :_:;._. show a marked similarity between the 
 pathological effects, and an ulcerating epith- 
 
 a : and while I cannot report a ca 
 cure. I feel confident that the pi gross of the 
 ulceration has been arrested, and that the 
 
EPITHELIOMA OF THE GUMS. 65 
 
 neoplastic histogenesis has been controled 
 by its use. Equal parts of the fluid extract 
 and glycerine, should be brushed over the 
 ulcer daily, and the first trituration adminis- 
 tered internally. 
 
 Phytolacca, has received favorable men- 
 tion, for the treatment of epithelioma of the 
 mouth. 
 
 Galium aperinum is also accredited with 
 curative properties, in epithelioma of the 
 mouth. 
 
 In one case, of most rapidly destructive 
 epithelioma, that began near the last lower 
 molar tooth, and spreading backwards in- 
 volved the pharynx, I succeeded in arresting 
 for a time, the destruction, by daily applica- 
 tion of the Chloride of Chromium. In all 
 these cases, the surgeou labors under the 
 disadvantage of being consulted too late, and 
 therefore it is impossible to say what the 
 effect of treatment would be, if applied early 
 in the history of the disease. 
 
 From the nature and position of the tissues 
 attacked, after the disease has become exten- 
 sive, any operation to be effective, would 
 involve formidable mutilation. While the 
 disease is confined to the region of the jaw, 
 
66 EPITHELIOMA OF THE MOUTH. 
 
 even after the alveoli and bone are involved, 
 a section of the maxilla, or the entire removal 
 of the bone, may be made with the possible 
 effect of preventing a return of the neoplasm ; 
 but when the disease has invaded the larynx, 
 it is questionable surgery to remove that 
 organ. The operation may prolong life, but 
 it is a severe procedure, and the statistics of 
 the few cases in which it has been performed 
 for epithelioma, are not encouraging, either 
 in the immediate, or remote results. It is 
 quite certain, that when epithelioma has 
 invaded the larynx, it has also infiltrated 
 other parts, usually the cervical lymphatics, 
 and each one of these glands may become 
 the center for a new development of the 
 disease. 
 
 If therefore, epithelioma of the gum can- 
 not be operated upon, while still the disease 
 is local, even though the structures involved 
 are extensive, provided they are confined to 
 the cavity of the mouth, it is well to with- 
 hold the use of the knife, and depend uj)on 
 pharmacology for a cure. 
 
 It may be possible to arrest the progress 
 of the disease by the actual cautery, or the 
 nitrite of silver, but I have seen only tern- 
 
EPITHELIOMA OF THE GUMS. 67 
 
 porary relief follow such applications, and 
 have thought that the resulting reaction, 
 had the effect of exciting the neoplastic 
 process to fresh activity. 
 
 Unless the neoplasm is very large, and 
 involves much of the lower jaw, it will not 
 be necessary to incise the lower lip to effect 
 a removal of the diseased structures. By 
 freely dividing the mucous membrane be- 
 tween the gum and the lip, the growth can 
 be easily removed, with Liston's heavy cross- 
 cutting bone forceps. But if the diseased 
 structures cannot be so excised, the surgeon 
 must not hesitate to perform the more exten- 
 sive operation, of removal of the jaw. 
 
 Operations about the mouth, are very 
 likely to be complicated by blood flowing 
 into the larynx and embarrassing respiration. 
 To avoid this, and to do away with the use 
 of Trendelenburg' s laryngeal tampon, a rather 
 cumbersome apparatus that does not always 
 prove satisfactory, and the practice of per- 
 forming tracheotomy as a preliminary opera- 
 tion, and then packing the larynx with 
 sponges, Prof. Annandale has suggested 
 the feasibility of allowing the patient's head 
 to hang over the edge of the table. His 
 
68 EPITHELIOMA OF THE MOUTH. 
 
 method deserves warm commendation, for 
 not only does the dependent position of the 
 head afford natural drainage of the mouth, 
 but by not interfering with respiration, ren- 
 ders tracheotomy unnecessary. Though the 
 tongue falls back towards the pharynx after 
 division of the genio-glossus muscles, the 
 epiglottis is not closed, and breathing con- 
 tinues to be perfectly easy. 
 
 To remove half of the lower jaw, it will be 
 found convenient to extend the incision 
 along the margin of the bone, from the lobe 
 of the ear, to the median line. If necessary 
 to further expose the bone, a vertical incision 
 through the lip, may be made to join the 
 first incision. After securing the facial 
 artery, the cheek is dissected from the jaw, 
 to an extent required by the tissue to be 
 removed, taking care to avoid wounding the 
 facial nerve. After extracting a tooth at the 
 point where the bone is to be divided, the 
 latter oi3eration may be performed with a 
 small straight-backed saw, or with the chain 
 saw, which I prefer for this purpose. By 
 now seizing the bone with the "lion-forceps," 
 it may be drawn out, and allow room to run 
 the knife along its inner surface, keeping 
 
EPITHELIOMA OE THE GUMS. 69 
 
 close to the bone, to avoid wounding the sub- 
 maxillary gland and lingual nerve. After 
 dividing the pterygoid muscle, traction on 
 the bone will depress the coronoid process, 
 so that the temporal muscle is easily sepera- 
 ted from its attachment. If now the knife is 
 passed in front of the joint, dislocation will 
 readily be accomplished, and by cautiously 
 cutting behind the bone, the latter may be 
 wrenched from the face. It is important at 
 this stage of the operation, to exercise the 
 utmost gentleness, for the condyle and neck 
 of the maxilla are easily forced against the 
 internal maxillary artery, to injure which, 
 would unnecessarily complicate the opera- 
 tion. 
 
 The after treatment, as well as the opera- 
 tion, should be conducted upon strict anti- 
 septic principles. For this purpose, I prefer 
 the bichloride of mercury, 1-1000. Before 
 closing the wound, it is well, as recommended 
 by Mr. Christopher Heath, to apply the 
 actual cautery to the cut surface of the bone, 
 for the purpose of removing rough pieces, 
 and of arresting any oozing that may take 
 place. 
 
 The drainage tubes being in position, and 
 
70 EPITHELIOMA OF THE MOUTH 
 
 their placing is a matter of the first import- 
 ance, the wound should be dusted with 
 iodoform, which has a specific action upon 
 the healing of bone, and the flaps brought 
 together with both deep and superficial 
 silver sutures. Over the wound, carrying 
 out the principle of a dry dressing, which I 
 believe to be the true antiseptic dressing, is 
 placed a large compress of sublimated cotton, 
 and the whole secured with the usual head 
 and face bandage. 
 
 Without disturbing the dressing, the 
 mouth should be frequently cleansed with 
 a solution of chloride of zinc, thirty grains, 
 to one ounce of water; or of permanganate 
 of potassium, about 1-1000. 
 
 In the place of the sublimated cotton, it 
 may be well to dress the wound internally 
 and externally, with iodoform gauze, as 
 suggested and practiced by Prof. Billroth at 
 his clinic in Vienna. His success in opera- 
 tions about the mucous passages, is almost 
 phenomenal, and should stimulate other 
 surgeons, to obtain like results with the 
 methods he employs. 
 
 The dressing should not be disturbed, 
 unless symptoms of inflammation develop, 
 
EPITHELIOMA OF THE GUMS. 71 
 
 before the eighth day, when the wound will 
 be found to have so far healed, as to make 
 removal of the sutures and drainage tubes 
 safe. 
 
 The use of a mechanical appliance to pre- 
 vent the contraction of the muscles of the 
 remaining portion of the jaw, is probably of 
 doubtful propriety. For it has been found 
 almost impossible to so keep the bone in 
 position, and the pain caused by any appar- 
 atus thus far devised, is sometimes intense, 
 and cannot be endured. If left to natural 
 processes, the parts will adapt themselves to 
 their new relations, better than when art 
 interposes, to produce certain results. 
 
 Epithelioma of the upper gum is rarely a 
 primary disease, but usually secondary to 
 the development of the neoplasm in the 
 antrum. In this cavity, squamous epithe- 
 lioma develops to an alarming extent, before 
 its presence is suspected, or with only such 
 swelling of the face, and illy defined pains, 
 as may be attributed to neuralgia, or an 
 ulcerated tooth. Indeed the trouble is fre- 
 quently believed to be an ulcerated tooth, 
 and the supposed diseased tooth extracted. 
 The true nature of the disease is then made 
 
72 EPITHELIOMA OF THE MOUTH 
 
 evident, by the destruction of the floor of 
 the antrum, and the subsequent protrusion 
 of the epithelial mass through the alveolus. 
 
 Or epithelioma may be mistaken for an 
 abscess of the antrum, and the existence of a 
 neoplasm not diagnosed, until the antrum 
 wall is punctured, for the evacuation of the 
 supposed pus. 
 
 Before the conditions are present, favor- 
 able for a microscopic examination, the age 
 of the patient is the most important factor in 
 deciding the nature of the disease. Swelling 
 and pain of the superior maxilla, occurring 
 in a person over fifty years of age, would 
 lead to a suspicion, of grave and malignant 
 disease of the antrum. 
 
 Unfortunately the age of those suffering 
 from epithelioma of the antrum, is opposed 
 to the success of so grave an operation as the 
 removal of the superior maxillary bone ; but 
 the rapidity with which the disease invades 
 the deeper structures, places the only chance 
 of relief, iu the most active, and thorough 
 extirpation of the neoplasm ; and this means 
 nothing less than removal of the superior 
 maxillary bone. 
 
 The removal of the superior maxilla, is 
 
EPITHELIOMA OF THE GUMS. 73 
 
 best accomplished by following the line of 
 incision suggested by Sir. Wm. Fergnsson. 
 
 To expose the bone sufficiently for its ex- 
 cision, and at the same time to avoid the 
 unsightly scar and contraction that remain 
 after destroying the angle of the mouth, 
 which necessarily divides the facial nerve, 
 as proposed by Mr. John Lizars the first 
 surgeon to demonstrate the possibility of 
 removing the entire superior maxillary bone, 
 Sir. Wm. Fergusson carried the incision 
 through the median line of the lip, into the 
 nostril, and if necessary, prolonged the in- 
 cision up the side of the nose, to end in a 
 curve under the orbit, that terminated at its 
 outer angle. Besides the advantages of this 
 incision, already mentioned, the extent of 
 the mutilation may be regulated by the judg- 
 ment of the surgeon, as he proceeds with 
 the operation. 
 
 After freeing the ala, and dissecting up 
 the tissues that form the lower flap, the in- 
 cisor teeth of the bone to be removed are 
 extracted, and the alveolus and hard palate 
 divided with a straight narrow saw, passed 
 through the nostril. The same instrument 
 begins a division of the nasal process of the 
 
74 EPITHELIOMA OF THE XOrTH 
 
 superior maxilla, and the malar bone, that is 
 completed with the bone forceps. The bone 
 is now seized with the "lion-forceps.*' and 
 separated from the palate bone, and ptery- 
 goid process. Before laving the knife aside, 
 the infra-orbital nerve is divided, and the 
 soft palate severed of its attachment to the 
 bone. 
 
 After arresting hemorrhage with animal 
 ligatures, and the actual cautery, which 
 should always be used, and when all oozing 
 has ceased, the parts are to be dusted with 
 iodoform, and the flaps brought together 
 with hare-lip pins, and silver sutures. 
 
 In adjusting the severed lip, the utmost 
 care should be observed to maintain the line 
 of the vermilion border. As. in the operation 
 for hare-lip. contraction may take place, it is 
 sometimes well to curve the border of the 
 flap, and so lengthen the line of the incision. 
 The same dressing and after treatment are to 
 be used, as recommended for excision of the 
 lower jaw. For the pain and shock that fol- 
 low this operation, no remedy will be found 
 of greater service than Hypericum* but to 
 obtain the best results, it must be adminis- 
 tered in drop doses of the tincture. 
 
EPITHELIOMA OF THE PALATE. 75 
 
 Primary epithelioma of the palate, is 
 a very rare disease. The seat of the neo- 
 plasm is usually in the antrum, the floor of 
 which being destroyed, permits the epithe- 
 lial mass to occupy the palate. 
 
 When epithelioma is a primary disease in 
 the roof of the mouth, it probably developes 
 in the mucous glands of this region. 
 
 The first evidence of the neoplasm is a 
 small hard tumor, situated beneath the 
 mucous membrane, to which it seems adher- 
 ent. The tumor shows the same disposition 
 to ulcerate, that marks epithelioma in other 
 parts of the mouth, and the ulcer presents 
 the usual characteristics of epithelial neo- 
 plasms. The pain extends to the face and 
 head, and the cervical glands participate in 
 the neoplastic process. 
 
 Histologically, primary epithelioma of the 
 palate, is probably always a mixed neoplasm, 
 containing epithelial, and connective tissue 
 cells. When a secondary development, it par- 
 takes of the nature of squamous epithelioma, 
 resembling in its anatomy, epithelioma of 
 the antrum, of which it is a part. 
 
 The medical treatment has been referred 
 to ; the surgical treatment will vary with 
 
76 EPITHELIOMA OF THE MOUTH 
 
 the origin of the disease, and the tissues 
 involved. If the neoplasm is developed in 
 the antrum, excision of the superior maxilla 
 will be necessary, but if it originates in the 
 epithelium of the palate, possibly the dis- 
 ease can be eradicated by removing as much 
 of the bone as the neoplasm involves. If it 
 is desired to remove the palate plates of the 
 superior maxilla, and of the palate bone, the 
 excision may be accomplished, by first ex- 
 tracting two of the molar teeth, through the 
 alveol of which, access is gained' to the 
 cavity of the antrum. With a strong scalpel, 
 the integuments covering the palate, are 
 then incised down to the bone, in a line cor- 
 responding to the floor of the antrum. 
 
 With Liston s bone forceps, curved on the 
 flat, or with a small boue chisel, the hard 
 palate can then be cut through, in the line of 
 the tegumentary incision. If the soft palate 
 is not involved in the disease, it can be sev- 
 ered from the bone, and allowed to remain. 
 The deformity resulting from this operation 
 could be overcome by a plate adjusted to form 
 an artificial roof to the mouth. I am not 
 aware that this operation has before been 
 rproposed : anatomically it is correct, piac- 
 
EPITHELIOMA OF THE TONGUE. 77 
 
 tically it is feasible for diseases that involve 
 only the floor of the antrum, and hard palate. 
 But it is rare for an epithelioma to be con- 
 fined to that part of the maxilla, or to the mu- 
 cous membrane of the roof of the mouth. The 
 surgeon's efforts to arrest the disease therefore, 
 are likely to result in failure, for it is absolute- 
 ly necessary, in removing a recurrent 
 neoplasm, to cut through perfectly healthy 
 tissue. 
 
 Mr. Heath's suggestion, to apply the 
 chloride of zinc paste after operating upon 
 epithelioma, I have found to be a valuable 
 adjunct to the treatment. The paste is to be 
 applied on strips of lint, and all possibility 
 of its escape into the mouth prevented, by 
 careful packing over the lint. The paste 
 should not be allowed to remain in the wound 
 longer than three days. While the sloughs 
 are seperating, I have found nothing better 
 then the permanganate of potassium solution, 
 with which to syringe the mouth. 
 
 Epithelioma of the tongue, is usually 
 a primary neoplasm, it being very rare for 
 the disease to spread to that organ, from 
 other parts of the buccal mucous membrane. 
 
 The initial forms do not differ from those 
 
78 EPITHELIOMA OF THE MOUTH 
 
 that mark the first stages of other varieties 
 of squamous epithelioma ; but to these two 
 forms, the nodule, and the abrasion or fissure, 
 there may with propriety be added a third 
 initial process, in which the tongue is de- 
 nuded of its epithelial covering. The latter 
 is interesting, not only because of its com- 
 parative rarety, but also because of the 
 probability that this pathological condition, 
 is but slightly, if at all, removed from 
 either the sub-acute, or chronic forms of 
 superficial glossitis. In the early stages it is 
 impossible to distinguish a case of glossitis, 
 — for which disease Schwimmer has suggested 
 the name leucoplakia — that is to pursue a 
 perfectly benign course, from a case that is 
 to terminate in one of the most malignant of 
 neoplasms. 
 
 But though these distinct initial forms are 
 noticed, there is nothing in the ulcerated 
 neoplasm, to indicate the particular process 
 in which it began. 
 
 Though epithelioma may develop where 
 ever epithelial cells exist, it attacks by pref- 
 erence the sides, — especially the right bor- 
 der—, the back, and the tip, of the tongue. 
 It is possible that the exciting cause of the 
 
EPITHELIOMA OF THE TONGUE. 79 
 
 disease, determines, to a certain degree, the 
 seat of the neoplasm ; and that the part of 
 the tongue invaded, influences the course 
 that the disease follows. 
 
 The age at which epithelioma of the tongue 
 develops, agrees with the jjeriod of life that 
 has been found favorable to the genesis of 
 this neoplasm in other organs. Epithelioma 
 is always a disease of decay, and hence we 
 find that its occurrence is most frequent 
 between the ages of forty and sixty. 
 
 It is also found, that the majority of cases 
 occur in men ; indeed if we exclude from our 
 statistics epithelioma of the. uterus and mam- 
 mary gland, the male sex is shown to be 
 more susceptible of the disease than the 
 female sex. It does not appear that physical 
 decay is more marked in men than in 
 women ; neither are they called upon to 
 endure anything that corresponds to the de- 
 mands upon nutrition, and physical and 
 nervous strength, that belong to the female 
 function of reproduction and parturition. 
 Perhaps we are nearer an understanding of 
 the greater frequency of epithelioma of the 
 tongue in men than in women, when we regard 
 some of the acquired conditions of life, and 
 
80 EPITHELIOMA OF THE MOUTH 
 
 constitutions, to which men are preponder- 
 ate^ subject. 
 
 Foremost among the former, I place the 
 use of stimulants, in the form of tobacco, 
 alcohol, and highly seasoned food. As we 
 have seen, smoking alone, cannot be con- 
 sidered of much importance in the etiology 
 of epithelioma of the lip, but I am inclined 
 to otherwise regard the habit, in relation to 
 epithelioma of the tongue, especially when the 
 disease is developed at its apex. Here the 
 carbonate and acetate of ammonia, acetic 
 and carbolic acid, that are products of the 
 dry distillation that accompanies smoking 
 tobacco, exert their acrid qualities, and have 
 the effect of exciting proliferation of the 
 epithelial cells, to protect the under dying 
 structures ; or of denuding the tongue of 
 its epithelium. 
 
 In a lesser degree, but also contributing to 
 the irritation of. the buccal epithelium, and 
 adding to the prolonged action of the exces- 
 sive use of tobacco, are to be mentioned 
 alcohol and highly spiced food, more fre- 
 quently used by men than by women. The 
 latter fact, may so far contribute to the bane- 
 ful effect of smoking, as in a measure it 
 
EPITHELIOMA OF THE TONGUE 81 
 
 explains the immunity from epithelioma of 
 the lips and tongue, that is enjoyed by 
 women who so use tobacco. 
 
 Among the constitutions more frequently 
 acquired by men than by women, that con- 
 tribute to this greater frequency of epithelio- 
 ma of the tongue in males, I would assign a 
 prominent place to syphilis, especially in its 
 secondary stage. 
 
 Any long acting irritation of the epithelium 
 of the tongue, is capable of engendering 
 genetic changes, that result in an abnormal 
 proliferation of the epithelial cells. Such 
 conditions exist in superficial secondary 
 glossitis, in which there is no ulceration, but 
 an erosion, caused by irritating bodies. It 
 is not here intended to advance the opinion 
 that syphilitic glossitis is an epithelial neo- 
 plasm, or that it can become an epithelioma, 
 but the belief is expressed, that if to a 
 specific glossitis, of the sclerous, not the 
 gummatous type, are added the decay and 
 cellular degeneration that belong to epi- 
 thelioma, local conditions exist that may 
 induce the epithelial neoplastic disease. 
 Syphilis in itself, causes premature decay, 
 and while it cannot be said that this is suffi- 
 
82 EPITHELIOMA OF THE MOUTH 
 
 cient to bring about such an issue, may not 
 the natural decay of the organism, acting in 
 connection with disease, exert an influence 
 in that direction. 
 
 Beyond age, and sex, the etiology of 
 epithelioma of the tongue probably includes 
 mechanical irritants. Of these, the principal 
 one will be found in ragged or broken teeth. 
 The disease develops at a time of life, when 
 the teeth are more or less unsound, and have 
 begun to decay, leaving sharp edges and 
 projections, which coming constantly in con- 
 tact with the tongue, cause a fissure in that 
 organ. The source of irritation continuing, 
 an ulcer that frequently becomes epithelio- 
 matous, develops. Of course there must be 
 other causes than the ragged teeth, in opera- 
 tion, for many persons suffer with such a 
 condition of their teeth, and do not have 
 epithelioma of the tongue. 
 
 Epithelioma of the tongue, is one of the 
 most certainly malignant forms under which 
 the epithelial disease appears. My own ex- 
 perience does not lead me to look upon the 
 neoplasm as rapidly destructive of life, if we 
 include the earliest recognizable pathological 
 lesion within the limits of the disease; but 
 
EPITHELIOMA OF THE TONGUE. 83 
 
 when the characteristic epithelial neoplastic 
 process is established, the fatal termination 
 is not far removed; between eleven and twelve 
 months, being the average duration of life. 
 
 A section made through epithelioma of the 
 tongue, shows under the microscope, the 
 same arrangement of epiblastic and mesoblas- 
 tic elements, that belongs to epithelioma 
 generally. The groups of epithelial cells are 
 more or less dense, and the connective tissue 
 stroma varies in consistence from embryonic 
 tissue, to closely packed fiber cells. Processes 
 of the epithelial structure, are seen to project 
 into the under-lying muscles of the tongue, 
 until finally, the disease having been allowed 
 to follow a natural course, the whole tongue 
 becomes involved in the neoplasm. The 
 covering of the ulcer contains broken-down 
 epithelial cells, cells that show their origin 
 in their irregular shapes, and in the 
 unimportant position occupied by the cell 
 nucleus. 
 
 Epithelioma of the tongue that has its 
 initial process in the nodular form of the 
 disease, is first noticed as a small, sharply 
 defined, smooth tumor, usually situated, 
 either at the base, or on the sides of the 
 
S4 EPITHELIOMA OF THE MOUTH 
 
 organ. The knot rests in apparently healthy 
 tissue, and is covered by mucous membrane 
 that shows no sign of the underlying 
 neojxlastie process. The nednle may remain 
 in this condition for a variable length of 
 time, attracting little attention save :: in an 
 increasing sense of stiffness of the ngue, 
 and an inability to articulate with accustomed 
 ease. In this stage of epithelioma of the 
 tongue, almost more than in an thei form 
 of epithelioma, is the nrely I : :al nati;: - : 
 the disease illustrated. Th- _ : 
 
 indicate that the pathology has extended 
 nd the boundary : the dc lule The 
 general health is excellent ; the tissues in 
 imm-r xmtact with the neoplasm are 
 
 normal, and the lymphatic .lands 
 show nc sign of infection. Th: ^t I 
 
 would designate as the quiescent period of 
 epithelioma. A period during which the 
 epithelial cells, though already started on 
 their pathological course neither multiply 
 so rapidly as to be forced beyond the 
 boundary of the primary nodule, nor de] 
 so far from physiological types and arrange- 
 ment, as to rx-ri: a leleterious influence 
 up::. mi. 
 
EPITHELIOMA OF THE TONGUE. 85 
 
 The causes that augment this pathological 
 process are not always discoverable. They 
 may be either, external — mechanical, or 
 within the neoplasm, and a part of the 
 neoplastic disease ; but being in operation, 
 the center of the nodule breaks down. This 
 is followed by ulceration of the integument; 
 by such an increase of the neoplastic cells as 
 to cause their projection in irregular masses, 
 into the lingual tissues ; and by an early 
 conveyance of the disease to the neighboring 
 lymphatics. The ulceration spreads deeply, 
 and does not long remain confined to the 
 tongue. The edge and base of the ulcer, 
 present the usual induration of epithelioma ; 
 the discharge becomes profuse and extremely 
 offensive, and the burning pain severe, and 
 almost constant. 
 
 If this process of destruction is not arrested, 
 the enlarged cervical glands so press upon 
 the oesophagus, as to interfere with 
 deglutition ; and the constant inhalation of 
 the effete discharge may induce septic 
 pneumonia, which in connection with maras- 
 mus, soon brings about a fatal termination. 
 
 Epithelioma of the tongue tJiat begins in 
 a crack or fissure, has its most frequent seat 
 
86 EPITHELIOMA OF THE MOUTH 
 
 at the rip or sides of the organ, and is 
 probably almost always located accidentally. 
 by an uneven and sharj} process of a tooth, or 
 by a wound that has resulted from masticating 
 food. 
 
 The fissure is at first insignificant, but 
 eventually becomes bounded by a nias^ of 
 densely packed epithelial cells, arranged in 
 groops that extend into the ad J 
 muscular tissue. 
 
 The subsequent course is in a great measure 
 a repetition of the nodular form of lingual ep- 
 ithelioma. The fissure deepens, and becomes 
 more widely spread ; the lymphatic glands 
 participate in the neoplastic process, and 
 excessive pain, and prostration, bring a 
 welcome close to life. 
 
 Epithelioma of the tongue, that has its 
 origin in leucoploJxia, j)resents a form of 
 neoplasm, less rapid in its course than the 
 neoplasms that we have been studying, but 
 not less certainly fatal, if unmolested. 
 
 Attention is first directed to a circum- 
 scribed, or general sensation of rawness of the 
 tongue, noticeable from its persistence, more 
 than its severity. The primary lesion is 
 usually attributed to a scald or burn, caused 
 by some article of food. 
 
EPITHLEIOMA OF THE TONGUE 87 
 
 If the tongue is examined at this time, there 
 are found, generally on the dorsum, one or 
 more dark red, smooth patches, that are but 
 little if at all, raised above the surrounding 
 mucous membrane. Suppuration, or a 
 discharge of any kind is not found at this 
 stage of the disease. There is no inflamma- 
 tion, and there is an absence of induration 
 of the under-lying tissues. 
 
 Without necessarily involving more super- 
 ficial tissues, as the apparently simple 
 "congestion of the epithelial layers" merges 
 into a malignant neoplasm, the base and 
 borders of this primary lesion become 
 indurated ; che hitherto mucous patch breaks 
 down, and is covered with cast off epithelial 
 cells. The lymphatic glands now show 
 evidences of infection, and what has become 
 an ulcerated epithelioma, is the seat of severe 
 burning, lancinating pains. 
 
 This form of epithelioma, preserves during 
 its whole course, certain characteristics that 
 point to the primary lesion. It is for 
 example, observed, that suppuration is never 
 profuse, and is sometimes quite absent ; and 
 that the process of destruction do^s not 
 involve the deeper structures, but tends to 
 spread superficially. 
 
88 EPITHELIOMA OF THE MOUTH 
 
 If epithelioma can in any of its forms be 
 regarded as a chronic neoplasm, the variety 
 that we are now studying is above all others, 
 deserving of that position in pathology. The 
 process of destruction may gradually increase 
 during an almost indefinite length of time, 
 before there is to be detected either lymphatic 
 infection, or constitutional involvement ; and 
 even often these features indicate the nature 
 and dissemination of the neoplastic cells, the 
 malignancy of the disease is neither as well 
 marked, nor as rapidly developed, as has 
 been observed in other forms of epithelioma. 
 
 A consideration of the frequency with 
 which leucoplakia precedes the development 
 of epithelioma of the tongue, is suggestive of 
 an analogy between this primary lesion, and 
 Paget' s disease of the nipple, in its relation 
 to epithelioma of the mammary gland. I 
 cannot consider the latter disease a variety 
 of eczema, but I am inclined to look upon it 
 as an epithelial neoplasm, and as much the 
 same process in the nipple, as the leucoplakia 
 that precedes epithelioma, is in the mucous 
 membrane of the tongue. 
 
 The diagnosis of epithelioma of the tongue, 
 is likely to be embarrassed, principally in the 
 
EPITHELIOMA OF THE TONGUE 89 
 
 direction of secondary and tertiary lesions, 
 of that organ. 
 
 The primary sore, and the secondary 
 mucous papule of syphilis, can with ordinary 
 care be eliminated from the question of 
 diagnosis ; but not so with the late secondary 
 infiltration, and ulceration, and the tertiary 
 gummata. 
 
 As a general distinguishing feature of all 
 specfic lesions, it will be remembered that 
 enlargement of the lymphatic glands takes 
 place early in the course of the disease ; this 
 fact, unless the question pertains to one of 
 the more rapidly malignant forms of 
 epithelioma, will at once suggest the nature 
 of the neoplasm. The age of the patient, 
 and the usual absence of pain, will also speak 
 in favor of a venereal taint. 
 
 The superficial syphilitic lesion, may some 
 times present an appearance that is very 
 similar to a superficial epithelioma ; but 
 in the floor of the former, there are frequently 
 developed cracks and fissures, which success- 
 ively heal and open, many times ; there is 
 also a tendency for the ulceration to spread 
 in one direction while healing in another, 
 both of which processes, indicate a power of 
 
90 EPITHELIOMA OE THE MOUTH 
 
 recuperation, that does not belong to 
 epithelioma. 
 
 The diagnosis between the ulcerated 
 gurnmata. and an ulcerated epithelioma that 
 originated in a nodule, is established with 
 less ease. After duly weighing the matters 
 of age. sex. lymphatic complication, and the 
 condition of the surrounding tissues, the 
 distinction will rest principally upon the 
 appearance of the lesion. 
 
 From the bottom of an ulcerated gumma, 
 which is usually deep, and as if scooped 
 out. there is more or less sloughing of 
 tissue. — a condition that does not obtain in 
 epithelioma, the surface of which is covered 
 only with broken dowu cells — , and the edges 
 are soft, undermined, and somewhat turned 
 in upon themselves, thus showing the base 
 of the ulcer to be more extensive than the 
 tegumentary lesion. 
 
 When however, any doubt exists as to the 
 true nature of the disease, a section of the 
 neoplasm should be subjected to a micro- 
 scopic examination, which may be relied 
 upon to confirm the diagnosis. 
 
 Treatment. The success of any method of 
 treating epithelioma of the tongue, will in a 
 
EPITHELIOMA OF THE TONGUE 91 
 
 measure depend upon the particular form 
 that the disease assumes, but will more 
 especially be influenced by the period at 
 which the case comes under treatment. 
 
 The medical treatment that has already 
 been suggested for epithelioma in other 
 parts of the mouth, may with equal propriety 
 be repeated in this place. 
 
 Especial mention may be made in favor of 
 gallum aperinum, for epithelioma of the 
 tongue ; and I would also direct attention to 
 the comocladia dentata, which produces an 
 ulcer, characterized by hard indurated edges, 
 and covered with a foul discharge. 
 
 But while it may be possible that medicines 
 are able to cure an epithelioma of the tongue,. 
 in view of the insidious nature of the disease, 
 and the finally rapid development of consti- 
 tutional symptoms, and secondary neoplasms,, 
 the question, how long is the surgeon justified 
 in trusting to the action of medicine, before 
 he removes the diseased part from the 
 organism, becomes one of serious import. 
 
 We are here dealing with a disease, the 
 initial process of which is local, but a disease 
 that with characteristic rapidity pervades the 
 entire system, and multiplies itself in remote 
 
92 EPITHELIOMA OE THE MOUTH 
 
 parts. If therefore, a case of epithelioma is 
 subjected to treatment, while it is a local 
 neoplasm, shall we give medicine, or shall 
 we, without delay, remove the tumor. Mod- 
 ern surgeons almost unanimously speak in 
 favor of the latter course ; but there may be 
 obstacles in the way of its adoption. First : 
 To make the operation thorough, it will not be 
 sufficient to remove the nodule of disease 
 only, the larger "portion of the tongue must be 
 amputated. The inconvenience to the 
 patient of the loss of his tongue, needs no 
 demonstration. There will therefore be a 
 natural desire to preserve the tongue, and a 
 disinclination to at once, resort to an opera- 
 tion ; but against the loss of the tongue, we 
 can place the final loss of life, if the disease 
 spreads beyond its local origin. 
 
 Then there is to be encountered the possi- 
 bility of a mistaken diagnosis, before the 
 development of those very constitutional 
 symptoms that render the results of any 
 method of treatment doubtful. Of course 
 the tongue would not be amputated on the 
 supposition that epithelioma was the disease, 
 and we have therefore now to decide what 
 treatment to pursue, in a case of more or less 
 
EPITHELIOMA OF THE TONGUE 9£ 
 
 ulcerated epithelioma, that may occur before 
 the system suffers. It is difficult to find 
 another answer than that just given; the 
 uncertainty of medicine, probably arising 
 from our ignorance, and the valuable time 
 lost in awaiting its action on one hand ; on 
 the other hand, the certainty that life will at 
 least be prolonged by an operation, — an anal- 
 ysis of 54 cases operated on, gives an average 
 duration of life of 19 months ; and an average 
 of 49 cases not operated on, an average of 
 11-7 months, showing a gain for operating 
 of 1-6 months. {Arthur E. Baker, Holmes 
 System of Surgery — ,) furnish support, to. the 
 more active and heroic course of treatment. 
 
 The position therefore of medicine, in the 
 treatment of epithelioma of the tongue, 
 seems to be limited to those cases that, either 
 from the extent to which the tissues are 
 involved in the neoplasm, or from some indi- 
 vidual reason, cannot be operated on. The 
 treatment is then palliative ; happily it may- 
 be curative. 
 
 It is now quite generally conceded, that 
 the development in the tongue of an obstinate 
 ulcer with an indurated base, in a person 
 over fifty years of age is sufficient to excite 
 
94 EPITHELIOMA OF THE MOUTH 
 
 grave suspicions of an epithelioma, and if no 
 improvement follows one or two weeks of 
 medical treatment, the neoplasm should be 
 removed without further delay. In these 
 cases, the question is frequently not one of a 
 cure, for unless every neoplastic center is 
 excised, the disease will return, but resolves 
 itself into affording temporary relief, and 
 prolonging life. 
 
 "We are now brought to a consideration of 
 the third principal obstacle to the excision of 
 the tongue for epithelioma, — the mortality 
 after the operation : but this one, like the 
 former two, will be found to grow less 
 formidable, when compared with the 
 death-rate that belongs to non-interference ; 
 and when the after-treatment, is more 
 successful in combating the results of an 
 operation. 
 
 The mortality after amputation of the 
 tongue has reached the high figure of 
 twenty-six per cent, but with improved 
 methods of meeting the principal source of 
 danger after this operation, — septic pneu- 
 monia — , the ratio has greatly decreased, for 
 in seventeen cases operated on at Prof. 
 Billroth' s Klinik, there did not occur a 
 single death. 
 
EPITHELIOMA OF THE TONGUE 95 
 
 The operation is not a particularly severe 
 one, and involves no organ that is essential 
 to life. The loss of blood need not be more 
 than trifling, and hence the conclusion is 
 reached, that the results of the operation 
 will depend upon the ease with which the 
 lungs become infiltrated with septic matter, or 
 irritated with the foul gases from the wound ; 
 and this will increase with the nearness of 
 the operation to the base of the tongue, and 
 the perfectness with which the after treat- 
 ment of the wound, overcomes these dangers. 
 
 Various methods have been proposed for 
 excising, and amputating the tongue; for rea- 
 sons already mentioned, the more extensive 
 operation will be most frequently called for 
 when the disease is epithelioma, and therefore 
 will especially engage our attention in this 
 place. 
 
 The operations for amputating the tongue, 
 differ principally in the manner of gaining 
 access to the mouth, and in the instruments 
 used to divide the organ ; the selection will 
 be made in accordance with the location of 
 the disease, and the extent of tissue involved. 
 "The propriety however, of removing all 
 diseased tissue, together with the lymphatic 
 
96 EPITHELIOMA OF THE MOUTH 
 
 glands at the root of the tongue, and in the 
 floor of the month, whether they show 
 evidence of disease or not. when the neoplasm 
 is epithelioma, will also influence the plan 
 made for each operation. 
 
 We may discard the older operation of 
 Roux, modified by Billroth and V. Langen- 
 beck. of gaining access to the tongue by 
 dividing the lower jaw. as an unnecessary 
 mutilation, excelling when the _t plasm 
 involves the gums and bony struct 1 ;: — 
 and even then it may be questioned whether 
 for such an extensive legeneratdon, any 
 operation could be justified — . for the entire 
 floor of the mouth can be cleaned out. :_ 1 
 the tongue removed at its base, without 
 injuring the bone, a grave complication of 
 any operation, and one likely to increase the 
 danger of septicaimia. 
 
 As the simplest operation that is consistent 
 with thoroughness will give the best 
 its, it is desirable if possible, to remove 
 the tongue through the mouth, without 
 making any preliminary incisions. Thi 
 be accomplished even when the disease is 
 situated at the base of the tongue. 
 
 A gag, that of Westmorland is a useful 
 
EPITHELIOMA OF THE TONGUE 97 
 
 instrument, is first introduced to hold the 
 jaws open. A strong whip-cord is then 
 passed through the tongue, and encharged to 
 an assistant, with directions to draw the organ 
 well forward, as soon as freed from its 
 anterior attachments, which constitutes the 
 next step in the operation. With a pair of 
 scissors, the mucous membrane, and genio- 
 hyoglossi muscles are then divided near the 
 jaw, thus leaving the tongue attached only 
 to the hyoid bone. The scissors may now be 
 laid aside, and the twisted wire cord, which 
 I find easier to apply than a whip cord, from 
 the fact that it better retains any angle to 
 which it may be bent, of a not too heavy 
 ecraseur, passed behind the seat of disease, 
 where it is held by needles that have been 
 made to transfix the tongue for that purpose, 
 before the chain of the ecraseur was adjusted. 
 If before beginning to tighten the instru- 
 ment, it is found that the previous dissection 
 of the floor of the mouth has not been 
 sufficient to allow the chain to cut behind 
 the diseased tissues, the tongue can be further 
 freed, by tearing its posterior attachments 
 with the fingers, or by the cautious use, of 
 blunt scissors. The operation is completed, 
 
98 EPITHELIOMA OP THE MOUTH 
 
 by slowly working the ecraseur until the 
 tongue is cut through. In no operation 
 about the tongue, do I find any advantage 
 from the use of the galvanic ecraseur. If 
 possibly it prevents hemorrhage, this effect 
 is more than counterbalanced, by the large 
 and foul slough of burned tissue that 
 remains after its use, and the danger of 
 secondary hemorrhage, when that slough 
 separates. Why should the attempt be made, 
 to remove one process of cell degeneration, 
 by establishing another process. 
 
 Without changing the instrument, if it is 
 not desired to amputate the tongue with the 
 ecraseur, the operation may be continued with 
 the scissors that accomplished the first 
 dissection, after the method proposed by Mr. 
 Whitehead, 
 
 This surgeon has performed successfully 
 the brilliant operation of snipping off the 
 tongue with scissors, without previously 
 ligating the lingual arteries, or taking any 
 other means, to prevent hemorrhage. He calls 
 his operation, "the bloodless operation." 
 While all surgeons agree upon the merits of 
 the procedure, there is not the same unanimity 
 of opinion as to its anatomical possibility. 
 
EPITHELIOMA OF THE TONGUE 99 
 
 The question is one of the hemorrhage that 
 attends the operation. Mr. Whitehead says 
 it is trifling, while other surgeons who have 
 followed his method, say that the hemorrhage 
 is most profuse, and only with difficulty 
 controled. It is certainly not easy to under- 
 stand why severing the lingual artery as near 
 its origin from the external carotid, as ampu- 
 ation at the base of the tongue must divide it, 
 would not be followed by such profuse 
 hemorrhage, as to require the application of a 
 ligature to the bleeding vessel. Until the 
 theory of haemostatics upon which Mr. 
 Whitehead bases his method is more fully 
 known, it seems probable that the "bloodless 
 operation" will not come into general favor 
 among surgeons. 
 
 After removing the tongue through the 
 mouth, it may be found tliat the disease has 
 spread more deeply than could before be 
 ascertained, and that it cannot be reached by 
 the natural orifice ; the plan first proposed by 
 Jaeger, of dividing the cheek, can then be 
 adopted. The incision should curve from the 
 last molar tooth, and terminate at the angle 
 of the mouth. It may be made on both sides 
 of the face. Although free access to the 
 
100 EPITHELIOMA OF THE MOUTH 
 
 tongue is gained by this method, the resulting 
 deformity from linear contraction, may, as 
 in removal of the superior maxilla, be very 
 considerable. 
 
 If the lymphatic at the base of the tongue, 
 and in the floor of the mouth, together with 
 the salivary glands, are involved in the morbid 
 process, their removal cannot be accomplished 
 through the mouth, either with ease, or with 
 success. Tlie floor of the mouth must then 
 be opened from below, and the principal part 
 of the operation performed through that 
 opening. 
 
 Among many others, three infra-maxillary 
 operations have been proposed, that will 
 meet most of the cases that require this more 
 elaborate operation ; I refer to the methods 
 of Prof. Kocher, Prof. Billroth, aud Mr- 
 Richard Bar well. 
 
 It will here be convenient to speak of 
 tracheotomy, and ligation of the lingual 
 arteries as preliminary operations in removal 
 of the tongue, for both procedures form 
 essential steps in the two first mentioned 
 operations. 
 
 Opening the trachea, greatly facilitates 
 any operation about the mouth that is likely 
 
EPITHELIUM OF THE TONGUE 101 
 
 to be attended with hemorrhage, for it 
 relieves the operator from the anxiety that 
 blood is flowing into the trachea and will 
 arrest respiration, and allows him to concen- 
 trate his attention on the operation. But I 
 believe that in many of the simpler operations, 
 it is an unnecessary addition to the already 
 considerable surgical risk. Mention has 
 already been made of Prof. Annandale's 
 method of allowing the patient's head to 
 hang over the edge of the table. This will 
 be found to sufficiently drain the mouth, 
 when the operation for removal of the tongue 
 does not include an infra-maxillary incision, 
 and is performed upon the anterior part of 
 the organ. 
 
 When tracheotomy is performed before 
 amputating the tongue, the pharynx is to be 
 carefully packed with a soft sponge to which 
 is attached a strong cord. The sponge should 
 be thoroughly cleansed with a, carbolic 
 solution before it is introduced. 
 
 The ligation of the lingual arteries before 
 amputating the tongue is a prudent step to 
 take, when the disease is extensive, or when 
 there is reason to believe that the walls of the 
 vessels will not hold a ligature. With the 
 
102 EPITHELIUM OF THE MOUTH 
 
 lingual arteries secured, the surgeon has 
 more freedom in selecting his operation, and 
 can use all necessary deliberation in 
 examining the diseased tissues. 
 
 The method by which Kocher gains 
 access to the buccal cavity, is a severe 
 operation, but probably affords a better view 
 of the posterior part of the tongue, and floor 
 of the mouth, and renders the removal of the 
 diseased structures easier, than any 
 operation yet proposed. 
 
 Tracheotomy is first performed. An 
 incision is then made on the anterior border 
 of the sterno-mastoid muscle from a little 
 below the lobe of the ear, to the hyoid bone. 
 Here an acute angle is formed, and the 
 incision continued upwards along the anterior 
 belly of the digastric muscle. By turning 
 the flap thus made upon the cheek, the 
 lingual artery is exposed, and ligated. B} r 
 this manoeuvre, the attachment of the tongue, 
 and floor of the mouth, are opened to inspec- 
 tion, and the removal of all the structures 
 that are implicated in the pathological 
 process, rendered possible. Kocher performs 
 the entire operation under the antiseptic 
 spray, and packs the cavity that remains, 
 
EPITHELIOMA OF THE TONGUE 103 
 
 with Listerian gauze, or a carbolized sponge. 
 The wound is not held together with sutures, 
 but is allowed to granulate, the discharges 
 being received into the absorbent dressing. 
 If drainage tubes are introduced into the 
 angle of the wound, sufficient drainage could 
 be maintained, at the same time that the flaps 
 are sutured. The tracheotomy tube is not 
 removed until the wound is well healed. 
 
 Billroth' s operation is a modification of 
 Rignoir s. He makes a curved incision that 
 extends along the lower border of the inferior 
 maxilla, from angle to angle of the bone. 
 Through this opening, the tongue and dis- 
 eased structures, after being freed from their 
 anterior attachments, are drawn, and excised. 
 But this operation, does not offer the facility 
 for thorough work, or for removing the 
 tongue at its base, that are given by Kocher's 
 method. 
 
 The use of the ecraseur through the infra- 
 maxillary incision, possesses some advantages 
 over the operation with the knife or scissors, 
 that commend its adoption when the 
 epithelioma is principally confined to the 
 tongue. 
 
 The operation performed and practiced by 
 
I 4 EPITHELIUM OF THE MOUTH 
 
 Mr. Richard Bar-well, is deserving of especial 
 iteration, from the ease with which it 
 may be performed, and the a scess :hat has 
 attended its - - 
 
 After placing a gag between the teeth, the 
 tongue is controled, not drawn ont of the 
 month, a point insisted upon by Mr. BarweD, 
 
 eans of a cord passed through the raphe. 
 An incision about a quarter of an .inch long, 
 is made in the median line, from the hyoid 
 bone forward, and often dividing the mylo- 
 hyoid muscle, and separating the genio-hyoid 
 and genio-hyoglossus muscles from their fel- 
 
 :he root of the tongue is reached. With a 
 Edston's needle, the point of which is guided to 
 a little beyond the last molar tooth, by the 
 forefinger placed in the mouth, a loop of 
 thread is carried to the side of the tongue. 
 A single thread is in the same manner carried 
 to the other side of the tongue. The wire of 
 an ecraseur. is then by the last introduced 
 thread, carried through the supra-L; i 
 incision, to the side of the tongue, and often 
 passing across the posterior aspect of the 
 organ, is made to emerge at the point of 
 entrance, by means of the first introduced 
 loop. After attaching the wire to the body 
 
EPITHELIUM OF THE TONGUE 105 
 
 of the instrument, its exact position may be 
 ascertained by passing the finger along the 
 dorsum of the tongue. In front of the line 
 where the tongue is to be divided, a Liston's 
 needle should be passed, to hold the wire in 
 place. After the base of the tongue is cut 
 through, the tissues that still hold the 
 anterior part of the organ, are divided by 
 means of the ecraseur, worked through the 
 mouth. 
 
 Any one of these four operations for re- 
 moving the tongue, give ample room to ex- 
 cise the healthy lymphatic glands situated 
 in that region, but when the glands become 
 the seat of secondary deposits, and thus the 
 possibility increases of leaving some diseased 
 structures in the mouth, the operation of 
 Kocher, will be most satisfactory. 
 
 Upon the treatment after amputation of 
 the tongue, much of the success of the oper- 
 ation depends. The operation should be 
 strictly antiseptic, to which end, my exper- 
 ience leads me to speak in favor of the 
 bi-chloride of mercury, 1-1000, carbolic acid 
 being still retained for use as a spray. I 
 have not yet seen any bad effects from the 
 use of mercury so prepared, and I find that 
 
106 EPITHELIOMA OF THE MOUTH 
 
 wounds generally, heal more rapidly, than 
 when cleansed with any other antiseptic. 
 
 After the operation, and when all oozing 
 has ceased, it may be well to wash the parts 
 with a solution of the chloride o± zinc, though 
 in many cases this is unnecessary. 
 
 Iodoform makes the best permanent dres- 
 sing for operations upon malignant diseases of 
 the mouth, that has yet been proposed. The 
 parts should be well dusted with the dry 
 powder, and then covered, either with the 
 adhesive iodoform gauze of Billroth, or 
 sublimated cotton. The external wound may 
 be treated in the same manner. 
 
 Both the internal and external dressings 
 should remain undisturbed, as long as the 
 character of the discharge, and condition of 
 the patient, render it safe to delay interfer- 
 ence. One of the advantages of a preliminary 
 tracheotomy, is that this very essential rest 
 of the parts is possible, for the patient can 
 be sustained by enemata, and respiration is 
 carried on through the tracheal tube. 
 
INDEX. 
 
 PAGE 
 
 Acetic acid, product of tobacco smoke, . 80 
 
 Acquired conditions of life, effect of upon epi- 
 thelioma, . . . . 79 
 Alcohol, effect of upon the development of epi- 
 thelioma, . . . .80 
 Ammonia, acetate, and carbonate, products of 
 
 tobacco smoke, . . . 80 
 
 Anaesthetics, preference for in operations, 58 
 
 Annandale's, Prof., position of the patient's 
 
 head during operations, . 67, 101 
 
 Antiseptic method, the necessity of using, 105 
 
 " principles of, . . 69, 70 
 
 " spray, use of in Kocher's operation, 102 
 
 Antrum, abscess of, . . . 72 
 
 " epithelioma of the, . . 71,75 
 
 " diagnosis of epithelioma of the, . 72 
 
 " method of gaining access to the, 76 
 
 Arsenic, use of in epithelioma of the lip, . 58 
 
 Asafcetida, use of in epithelioma of the lip, 58 
 
 Barwell's, Mr. Richard, amputation of the 
 
 tongue, . . . . 100, 104 
 
 Billroth's, Prof., amputation of the tongue, 100, 103' 
 
108 INDEX. 
 
 Billroth's, Prof., iodoform gauze, . 70 
 klinik, ... 94 
 " " modification of Roux amputa- 
 tion, .... 69 
 " Bird nest bodies," in epithelioma, . 38 
 Bloodless operation of Mr. Whitehead, 98 
 
 Cachexy, explanation of, . . 31 
 Carbolic acid, product of smoke, . 80 
 Carbolic acid, use of for spray, . . 105 
 Carcinomatous tissue, not all included in the de- 
 structive process, . . . 34 
 " Catalytic action," ... 36 
 CausticSjtreatment of epithelioma of the lip with, 56 
 Cautery, use of actual, in epithelioma, . 66 
 " use of, before closing the wound, 69 
 " use of actual, for hemorrhage, 1\ 
 Cervical glands, involvment of in epithelioma 
 
 of the lips, . 50 
 Cervical glands, involvment of in epithelioma 
 
 of the palate, ... 75 
 
 Chancre, appearance of, . . . 51 
 
 " discharge from, . . 53 
 
 Cheek, Jaeger's method of dividing, . 99 
 
 Chloride of chromium, use of in epithelioma, 65 
 
 Chloroform, preference for the use of, . 58 
 
 Clematis, the use of in epithelioma of the lip, 58 
 Comocladia, the use of in epithelioma of the 
 
 tongue, .... 91 
 
INDEX. 109 
 
 Condylomata, in the development of epithelioma, 35 
 Conium, the use of m epithelioma of the lip, 58 
 Connective tissue, the base of glands, . 15 
 
 Constitution, the relation of an acquired, to epi- 
 thelioma, . . . . 81 
 Contraction, linear, after dividing the cheek, 100 
 Corium, relation of, to epithelial cells, . 18 
 Drainage, Prof. Annandale's method of, 68 
 Drainage tube in Kocher's operation, . 103 
 " " position of, . .69 
 Dressing, the time for removing, . 70 
 Ecraseur, use of the galvanic, . . 98 
 " the use of in amputation of the 
 tongue, . . . 97, 103 
 Embryo, differentiation of the layers of, . 14 
 Enemata, the use of to administer food, 106 
 Epiblastic layer, . . . .13 
 Epithelial cells, . . . 16 
 " " effect of numerical increase of, 31,32 
 " " contents of, . . 17 
 " " nucleus of, . 17 
 " " life cycle of, . . 26 
 " " metamorphosis of, . 16 
 " " physiological function of, 16 
 " " shape of normal, . 38 
 " " vacuolation of, . . 44 
 Epithelial neoplasms, clinical history of, 29 
 " " resemblance of to gland- 
 ular tissue, . . . .29 
 
110 INDEX. 
 
 Epithelial tissue, general features of, . 15 
 
 Epithelioma, beginning of, in a fissure, . 35 
 " causes that determine the location 
 
 of, ..... 79 
 
 Epithelioma, development of. in adolescence, 45 
 
 development of. in epithelial cells, 7^ 
 
 dividing line of, not well marked, 39 
 
 diagnosis of, . . 35 
 
 discharge from, . . 52 
 
 edges of, ... 90 
 
 of the gams, . . . 61 
 
 of the upper gums. . 71 
 
 indurated base of, . . 34 
 
 inheritance of, . . 47 
 
 local origin of, . . 46 
 
 of the mouth, . . 39 
 
 nodular form of, . . 33 
 
 of the palate, . . 75 
 
 physical decay related to the de- 
 velopment of, . . . .45 
 Epithelioma, reasons for the immunity enjoyed 
 
 by some parts of the mouth, from, . 40 
 
 Epithelioma, removal, effect of upon, in the 
 
 earliest stages, . . . 47 
 
 Epithelioma of salivary glands, . . 3 7 
 
 , section of, . . 63 
 
 " . squamous, of the antrum, 71 
 
 " , surface of, . . . 60 
 
 " of the tongue, . . 7 7 
 
INDEX. Ill 
 
 Epithelioma, ulceration of, . . 34 
 
 Epithelium, columnar cells of, may assume the 
 
 function of mucous glands, . 43 
 
 Epithelium, deeper layers, office of the, . 21 
 
 " glandular, . . 15 
 
 " investing of the mouth, . 17 
 
 " regeneration of, . . 18 
 " varicose fibrils of columnar cells of, 25 
 
 " vascular system of, . 18 
 
 Etiology of epithelioma, age as a factor in, 44 
 " " " functional activity of 
 
 glands as a factor in, . . 40 
 
 Etiology of epithelioma, injuries as a factor in, 40 
 " " " derangement of diges- 
 tive organs, as a factor in, . . 42 
 
 Etiology of epithelioma, physical decay as a 
 
 factor in, . . . 43 
 
 Fergusson's, Sir W., incision for the removal 
 
 of the superior maxilla, . . 73 
 
 Folding up process, the effect of, upon gland 
 
 cells, .... 45 
 
 Frsenum linguae, . . . .22 
 
 Gag, Westmoreland's, ... 96 
 
 Galium, use of in epithelioma of the gums, 65 
 
 " use of in epithelioma of the tongue, 91 
 
 Glands, the alveoli of, . . . 23 
 
 " " center of epithelioma, . 66 
 
 " " development of, . . 14 
 
112 INDEX. 
 
 Glands, the digestive, effect of senile period upon, 44 
 " " ducts of mucous, . . 22 
 " " earl)- infiltration of . 56 
 " " excretory duct of, . . 23 
 " " mucous, the formation of, . 21 
 " mucous, the lining of, . . 22 
 " the situation of 3 . . 22 
 " salivary, . . . 14, 22 
 " tubular, the seat of epithelioma, . 36 
 Glossitis, superficial, the relation of, to epithe- 
 lioma of the tongue, . . 73, 81 
 Gummata, diagnosis of, from epithelioma of 
 
 the tongue, .... 90 
 Gums, causes of epithelioma of, . 63 
 " diagnosis of epithelioma of. . 63 
 " epithelioma of the, . . 61 
 epithelioma of the upper, . . 71 
 " floor of epithelioma of the, . 62 
 " operations for the removal of epitheli- 
 oma of the, .... 67 
 Gums, treatment of epithelioma of the, 64 
 Health, establishment of equilibrium in, . 49 
 Heath, Mr. Christopher, on the use of the ac- 
 tual cautery, . . . 69 
 Heath, Mr. Christopher, on the use of the 
 
 chloride of zinc paste, . . 77 
 
 Hemorrhage, in amputation of the tongue, 99 
 
 Histogenesis, transmission of a pathological, 48 
 Hookah, the use of in the East, 
 
INDEX. 113 
 
 Hydrastus, the use of in epithelioma of the lip, 58 
 Hydrochlorate, cocoaine, the anesthetic use of, 58 
 Hypericum, the use of in shock, . . 74 
 
 Infiltration of glands in epithelioma, . 56 
 
 Inheritance of epithelioma, . . 47 
 
 Involution of epithelial structures, relation of 
 
 to their pathology, . . - 43 
 
 Iodide of calcarea, the use of in epithelioma, 58 
 Iodoform, the use of in dressing wounds, 70, 74,106 
 Iodoform gauze of Prof. Billroth, . 70, 106 
 
 Irritation, a cause of epithelioma of the gums, 64 
 Jaegar's method of gaining access to the mouth, 99 
 Jaw, contraction of the muscles of, after its 
 
 excision, . . . .71 
 
 Kocher's, Prof., amputation of the tongue, 
 
 100, 102, 105 
 Labial glands, situation of, . . 41 
 
 Langenbeck's, V., the operation of, . 96 
 
 Leucoplakia, relation of to epithelioma of the 
 
 tongue, . . . . 78 
 
 Life, average duration of, in epithelioma of 
 
 the lip, ... 55 
 
 Life, prolongation of, by operating for epithe- 
 lioma of the tongue,. . . 93 
 Ligature, the animal, in hemorrhage, . 74 
 Limiting membrane, absence of in epithelioma, 39 
 Lingual arteries, the ligation of, . 100, 102 
 " glands, the situation of, . . 41 
 
114 INDEX. 
 
 Lips, adjusting the severed, . . 74 
 
 " destruction of, caused by epithelioma, 50, 53 
 " early stages of epithelioma of the, . 50 
 
 " epithelioma of the, . . 49 
 
 " epithelioma of the, confounded with 
 other diseases, . . . 51 
 
 Lips, epithelioma of the, return of after operation, 56 
 " epithelioma of the. treatment of, with 
 
 caustic-. .... 66 
 
 " epithelioma of the, local treatment of, 58 
 
 Listerian Gauze, use of in Kocher's operation, 104 
 Liston's Bone Forceps, . . 6 7. 76 
 
 " Xeedles in Billroth's Operation, . 104 
 Lizars, Mr. John, operation of, . 73 
 
 Lymphatics, invaded in epithelioma of the 
 
 tongue, . . . . 85, 87 
 
 Lymphatics, early involvement of in syphilis, S9 
 " causes of invasion of the, . 39 
 
 Lymphatic glands, necessity of removing, in 
 
 amputation of the tongue, . 95, 106 
 
 Lymphatic glands, easily reached by Kocher's 
 
 operation, . . . . 105 
 
 Lupus, the corium the seat of, . 53 
 
 " resemblance of to epithelioma, . 53 
 
 Malignancy, causes of, ... 30 
 
 Malignancy, histological marks of superlative, 34 
 Malignant neoplasms, use of iodoform for, 106 
 
 Marasmus, causes of in epithelioma of the 
 
 tongue, . . . ^5 
 
IT^DEX. 115 
 
 Maxillary bone, changes induced by epitheli- 
 oma of the, ... 54 
 Maxillary bone, cannot be converted in epithe- 
 lial tissue, .... 62 
 Maxillary bone, removal of the superior, 68, 72 
 Medicines, how long shall they be exhibited 
 
 before operating, . . . 91 
 Medicines, the position of, in the treatment of 
 
 epithelioma of the tongue, . . 93 
 Mercury, bi-chloride, as an antiseptic, . 60, 105 
 Microscope, the use of, to differentiate neo- 
 plasms, . . . .52 
 
 Membrana propria, . . . 15 
 Men, causes of the more frequent development 
 
 of epithelioma in, . . 79 
 
 Men, epithelioma of the tongue in, . 79 
 
 Mortality, after amputation of the tongue, 94 
 
 Mouth, development of the, . . 13 
 
 " epithelioma of the, . . 29 
 
 " minute anatomy of epithelioma of the, 38 
 
 " epithelium of the, . . . 12 
 
 " origin of epithelium of the, . 33 
 
 " mucous glands of the, . . 21 
 
 " and pharynx, communication between the, 13 
 
 " the primitive, . . . 12 
 
 " simplest form of, . . . 14 
 
 Mucous glands, epithelium of the, . 75 
 
 " membrane, . . . 20 
 
 " origin of buccal, . . 21 
 
116 IXDEX. 
 
 Mucous, relation of columnar cells to the secre- 
 tion of, .... 20 
 Mueigen. . . . . 20 
 Neoplasms, origin of in peculiar poisons, . 32 
 Xitrite of silver, the use of in epithelioma. 66 
 Xornial methods, the prototype of abnormal 
 
 methods, .... -48 
 
 Xucleus, the situation of in columnar cells, 20 
 
 Xuhn, the glands of, . .' . 22 
 
 Operations, effect of upon life, . . 66 
 
 " for epithelioma of the lip, . 58 
 
 " " " of the palate, . 75 
 " " " of the tongue, 92, 95 
 " infra maxillary, for amputating 
 the tongue, .... 100 
 
 Operations, the simplest will give the best re- 
 sults, .... 96 
 
 Orientals, causes of immunity of the. from 
 
 epithelioma, . . . .54 
 
 Pabulum, extraction of from the blood, 31 
 Paget'Sj Sir James, disease of the nipples, com- 
 parison between, and leucoplakia, . 88 
 Pains, in epithelioma of the tongue, . 87 
 Palate, division of the. . . . 73 
 " deformity resulting from, . 76 
 " plates of the superior maxillary bone, 
 
 removal of the, . . . 76 
 
INDEX. 117 
 
 Palate, epithelial covering of the, . 19 
 
 " epithelioma of the, . . 75 
 
 " " histology of, . 75 
 
 " " treatment of, * . 75 
 
 Papilla? of the tongue, . . 19 
 
 Parotid gland, cells of the, . . 24 
 
 Permanganate of potassium wash, . 70, 77 
 
 Pharynx, origin of the, . . . 13 
 
 " packing of the, in tracheotomy, 101 
 
 Physical decay, a process of equilibration, 43 
 
 Phytolacca, the use of, in epithelioma of the 
 
 gum, ..... 65 
 Phytolacca, the use of, in epithelioma of the lip, 58 
 
 Ranunculus, the use of in epithelioma of the 
 
 gums, .... 64 
 Ranunculus, the use of in epithelioma of the 
 
 lip, ..... 58 
 Recurrent neoplasms, the essentials of operat- 
 ing upon, . . . . 77 
 Roux's amputation of the tongue, . . 96 
 Saliva, . . . . . 24 
 Salivary cells, multiplication of the, . 25 
 " glands, epithelioma of the, .. 36 
 " glandular epithelium, regeneration of, 24 
 '• glands, during the senile period, 44 
 Schwimmer, Prof., on leucoplakia, . 78 
 Senile period, effect of, upon the glands of di- 
 gestion, . . . .44 
 
118 INDEX. 
 
 Septicaemia, danger of, increased by dividing 
 
 the maxilla, ... 96 
 Septic matter, infiltration of the lungs with, 96 
 Shock, Hypericum in, ... 74 
 Smoking, as an etiological factor, . 54 
 Smoke, products of the dry distillation of, 80 
 Spray, the use of the carbolic acid, in amputa- 
 tion of the tongue, . . 105 
 Stimulants, effect of upon the development of 
 
 epithelioma, .... 80 
 
 Sublimated cotton, the use of, . 70, 106 
 
 Sub-lingual glands, the mucous cells of the, 23 
 
 Sub-maxillary glands, the mucous cells of the, 23 
 Sutures, the time for removing, after operating 
 
 on the lip, .... 60 
 Syphilis, complicates the diagnosis of epitheli- 
 oma, .... 89 
 Syphilis, relation of, to the development of 
 
 epithelioma, . . . .81 
 
 Syphilitic, lesions the floor of, . 89 
 
 Tampon, Trendelenburgh's, . . 67 
 
 " Taste buds " of the tongue, . . 19 
 
 Tobacco, effect of, upon the development of 
 
 epithelioma, .... 54, 80 
 Tongue, the age at which epithelioma develops, 79 
 " amputation of the, . . 95 
 
 " amputation of the, dangers to antic- 
 ipate from, . . . .95 
 
INDEX. 119 
 
 Tongue, causes of epithelioma of the, . 86 
 
 " characteristics of epithelioma of the, 85 
 
 " chronic character of epithelioma of the, 88 
 " development of epithelioma of the, in 
 
 men, . . . . .79 
 
 " diagnosis of epithelioma of the, 88, 90 
 
 " epithelioma of the, . . 77 
 
 " '" " originating in a 
 
 fissure, . . . . 85 
 
 Tongue, epithelioma of the, originating in leu- 
 
 coplakia, .... 85 
 Tongue, local character of epithelioma of the, 84 
 " malignancy of epithelioma of the, 82 
 mortality after amputation of the, 94 
 " nodular form of epithelioma of the, 83 
 " quiescent period of epithelioma of the, 84 
 " removal of the, through the mouth, 96 
 " removal of the, through an infra-max- 
 illary incision, . . . 100 
 Tongue, section of epithelioma of the, . 83 
 " situation of epithelioma of the, 83 
 " suspected epithelioma of the, . 94 
 " treatment of epithelioma of the, 90 
 Tracheotomy, advantage of, . . 106 
 " a preliminary operation, . 100 
 
 Ulcer, the bottom of an epitheliomatous, 51 
 
 " characteristics of an epitheliomatous, . 50 
 
 " edges of an epitheliomatous, . 49 
 
120 INDEX. 
 
 Vital changes, origin of, . . . 48 
 
 Waste cells, relation of to pathological forma- 
 tions, .... 45 
 Whip-cord, the use of in amputating the tongue, 99 
 Whitehead's Mr., amputation of the tongue, 99 
 Women, causes of their immunity from epithe- 
 lioma, ..... 81 
 Wounds, the dressing of, . . 60, 106 
 " the use of the dry dressing for, . 70 
 Zinc, paste of chloride of, after operating, 70 
 Zinc, wash of chloride of after operating, 59, 70, 106 
 

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