Columbia ^nibersiitp COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by 3 Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/manualofinjuriesOOmars Mo INJURIES AND SURGICAL DISEASES FACE, MOUTH. AND JAWS. JOHN SAYRE MARSHALL, M.D.(syr..un,v,), Former Professor of Dental Pathology and Oral Surgery, and Emeritus Professor of Oral Surgery of the Dental Department of Northwestern University. Former Professor of Oral Surgery of the American College of Dental Surgery. Attending Oral Surgeon to St. Luke's Hos- pital, Mercy Hospital, and Baptist Hospital of Chicago. Fellow ofthe American Academy of Dental Science. Member of the American Dental Association, and ofthe State Dental Society of Illinois. Member of the American Medical Association, and of the Cook County Medical Society. PHILADELPHIA : THE S. S. WHITE DENTAL MFG. COMPANY. 1897. Copyright, 1S97, by John Savre Marshall- To my friends and confreres, . JONATHAN TAFT. M.D.. D.D.S., AND S. B. PALMER, M.D.S., In remembrance of the kindly sympathy and encouragement so often extended in the earlier years of my professional life, this hook is affectionately dedicated by " THE AL'THOR. PREFACE. The plan of this volume is the outgrowth of several years' ex- perience as a teacher of Oral Surgery, in Medical and Dental Colleges. During these years the author has been more and more impressed with the disadvantages under which teachers and students have labored in the old system of teaching by didactic lectures. The same feeling has been growing, year by year, among many of the teachers in the Ameri- can j\Iedical and Dental Colleges, and many of them have expressed themselves as anxious to adopt a recitation system of teaching in their special departments. The greatest objection which has been raised to the inauguration of such a system of teaching has been the lack of text- "books arranged upon a suitable plan for teaching by this method. The author has endeavored to fill this requirement in the depart- ment of Oral Surgery by the preparation of this volume. In the selec- tion and presentation of the various subjects comprising the work, he has constantly kept in mind the particular needs of the medical and dental student. In Part First will be found those subjects which be- long to the General Principles of Surgery, while Part Second is devoted to the more conmion Injuries and Surgical Diseases which are asso- ciated with the Face, the Mouth, and the Jaws. These subjects have been divided into short chapters, suitable to class recitation work, and each chapter is followed by a series of review questions covering the most important facts presented upon each topic. These questions can be used by the teacher as a basis for class quizzes; they will also enable the student to quiz himself upon every subject presented. How well the author has succeeded in the undertaking he must leave to the criticism of his colleagues; but he trusts that the general plan will meet with the approval of all interested in a better system of teaching. The very excellent illustrations upon Bacteriologic and Pathologic subjects have been made from photo-micrographs especially prepared for this volume by the author's friend and confrere. Dr. Alda A. Latham, of the Bacteriologic Laboratory of the Woman's Medical Department of the Northwestern University, and he takes very great pleasure in making this acknowledgment. To Dr. William H. Knapp, of Chicago, he is also indebted for valuable services rendered in photographing some of these slides and for the photo-micrographs of the karyokinetic figures ; and to T. Charters White, of London, England, for several interesting photo-micrographs. Especial thanks are due to the various authors quoted in the work, for much valuable information gathered from their labors, and also to Dr. N. Senn, Mr. Christopher Heath, Mr. J. Bland Sutton, Dr. W. D. Miller, and to their publishers, W. B. Saunders, Churchill & Co., Cassell Publishing Company, The S. S. White Dental Manufacturing Compan)', and F. A. Davis, for courtesies extended in permission to use many valuable illustrations. John S.wre Marshall. 36 Washington St., Chicago. CONTENTS. PART I. CHAPTER I. Surgical Bacteriologv. PAGE Parasites. The Microscopic Study of Bacteria. Functions of Bacteria. The Pyogenic or Pus Microbes. Infection I CHAPTER II. Surgical Bacteriology (Continued). Action of Bacteria. The General Principles of Antiseptic Treatment 23 CHAPTER III. Inflammation. Inflammation. Irritation. Hyperemia. Exudation. Temperature. Pulse. Symptoms of Acute Local Inflammation. Description of the Inflam- matory Process in the Vascular Tissues 41 CHAPTER IV. Inflammation (Continued). Suppuration. Pus. Constitutional Symptoms of Acute Inflammation. Sthenic Fever. Asthenic Fever. Predisposing Causes. Symptoms and Diagnosis. Prognosis 55 CHAPTER V. Treatment of Inflammation. Curative Treatment. Local Treatment — Depletion — Rest — Cold — Heat. Constitutional Treatment — Diet 63 CHAPTER VI. Chronic Inflammation. Causes. Induration. Hypertrophy. Tumefaction. Fatty Degeneration. Caseation. Treatment — Local — Constitutional 7t CHAPTER VII. Abscess. Definition. Causes. Classification. Acute Abscesses — Symptoms — Treat- ment — Antiseptic Solutions. Methods of Opening Abscesses. Chronic Abscess — Causes — Symptoms — Treatment 7^ X CONTENTS. CHAPTER VIII. Ulceration. p Definition. Causes — Age — Sex — Occupation — Traumatism. Classification. Healing. Prognosis. Treatment — Operative — Constitutional CHAPTER IX. Necrosis, Caries, and Gangrene. Necrosis — Definition — Causes. Caries — Definition — Causes. Gangrene — Definition — Causes. Dry Gangrene or Mummification. Moist Gan- grene. Symptoms. Prognosis. Treatment 97 CHAPTER X. Traumatic Inki.ajimatory Fever. Definition, Treatment 109 CHAPTER XL Septicemia. Definition. Causes. Avenues of Infection. Sapremia — Symptoms. Symp- toms of Septicemia — Diagnosis — Prognosis — Treatment 114 CHAPTER XII. Pyemia. Definition. Predisposing Causes — Climate — Age and Sex. Active Causes. Symptoms. Diagnosis. Prognosis. Treatment 122 CHAPTER XIII. Erysipelas. Definition. Causes. Symptoms. Diagnosis. Prognosis. Varieties. Ery- sipelas of the Mucous Membrane. Treatment 131 CHAPTER XIV. Tetanus. Definition. Causes. Period of Incubation. Forms of the Disease. Acute Tetanus — Symptoms — Diagnosis. Chronic Tetanus — Prognosis — Treat- ment 143 CHAPTER XV. Shock and Collapse. Shock — Definition. Collapse. Pathology — Symptoms — Prognosis — Treat- ment. Shock from Dental Operations 152 CONTENTS. XI CHAPTER XVI. Ligatures, Sutures, and Suturing. PAGE Ligatures — Catgut — Kangaroo — Silkworm-gut — Silver Wire. Ligation of Vessels. Sutures — Continuous — -Interrupted — Pin — Quilled — Clamp — Button — Buried — Cobbler's — Shotted 164 PART II. CHAPTER XVII. Wounds. .Definition. Classification. Healing of. Methods of Healing — First Inten- tion — Second Intention — Third Intention. Surgical Cleanliness 173 CHAPTER XVIII. Tre.\tment of Wounds. Asepsis. Arrestation of Hemorrhage. Coaptation. Drainage. Physiolo- gical Rest. Dressings 185 CHAPTER XIX. Gunshot Woltnds. Diagnosis. Gunshot Wounds of the Face. Symptoms. Treatment 191 CHAPTER XX. Fractures of the Inferior M.\xilla. Definition. Fractures of the Alveolar Process. Of the Body of the Lower Jaw. Displacements. Lines of Fracture. Symptoms. Diagnosis. Prognosis 200 CHAPTER XXI. Fractures of the Inferior Maxill.a (Continued). Treatment. Abscess of the Jaws 208 CHAPTER XXII. Fractures of the Superior IMaxill.e and Upper Bones of the Face 224 CHAPTER XXIII. Delayed Union and Ununited Fractures. Causes. Treatment of Delayed Union — Of Ununited Fractures 238 CHAPTER XXIV. Dislocation of the Inferior Maxilla. Definition. Dislocations of the Lower Jaw — Causes — Symptoms — Treat- ment. Subluxation of the Jaw — Causes — Treatment 245 Xll CONTENTS. CHAPTER XXV. Anchylosis of the Jaws. „,_„ PAGE Definition. Temporary Anchylosis — Causes — Treatment. Permanent An- chylosis — Causes — Diagnosis — Treatment — Mechanical Treatment — Sur- gical Treatment 253 CHAPTER XXVI. Periostitis of the Jaws. Definition. Causes. Symptoms. Acute Diffuse Periostitis — Causes — Treat- ment. Mercurial Periostitis — Symptoms — Treatment. Chronic Perios- titis of the Jaws 262 CHAPTER XXVII. Necrosis of the J.\ws. Definition. Causes. Symptoms. Treatment 267 CHAPTER XXVIII. Necrosis of the Jaws (Continued). Exanthematous Necrosis — Symptoms — Treatment. Mercurial Necrosis — Treatment. Arsenical Necrosis — Treatment. Phosphorus Necrosis — Symptoms — Treatment. Syphilitic Necrosis — Symptoms — ^Treatment. Reproduction of Bone 272 CHAPTER XXIX. Stomatitis. Definition. Stomatitis Simplex — Symptoms — Treatment. Stomatitis Ca- tarrhalis — Causes — Symptoms — Treatment. Stomatitis Aphthosa — Treatment. Stomatitis Ulcerosa — Causes — Symptoms — Treatment 283 CHAPTER XXX. Surgical Tuberculosis. Tuberculosis — Avenues of Infection — Pathology 293 CHAPTER XXXI. Surgical Tuberculosis (Continued). Tuberculosis of Bone — Symptoms and Diagnosis — Differential Diagnosis — Prognosis — Treatment 304 CHAPTER XXXII. Surgical Tuberculosis (Continued). Tuberculosis of the Skin — Pathology. Tuberculosis of the Skin of the Face — Of the Mucous Membrane of the Mouth — Of the Tongue and Pharynx. Dift'erential Diagnosis. Prognosis. Treatment 318 CONTENTS. XUl CHAPTER XXXIII. Diseases of the Maxillary Sinus. PAGE Suppurative Inflammation of the Maxillary Sinus — Etiology. Devitalized Pulps. Alveolar Abscesses. Malposed Teeth. Foreign Bodies. Trau- matic Injuries. Catarrhal Affections. i\Iucous Engorgements 332 CHAPTER XXXIV. Diseases of the Maxillary Sinus (Continued). Suppuration of the Antrum of Highmore — Symptoms — Diagnosis — Differ- ential Diagnosis — Prognosis — Treatment 348 CHAPTER XXXV. Diseases of the Maxillary Sinus (Continued). Syphilitic Ulceration of the Antrum of Highmore — Diagnosis — Diiiferential Diagnosis — Treatment. Necrosis of the Walls of the Maxillary Sinus — Symptoms; — Treatment 357 CHAPTER XXXVI. Cystic Tumors of the Maxillary Sinus. Mucous Cysts of the Antrum — Symptoms and Diagnosis — Prognosis — Treatment. Polypus of the Antrum — Symptoms and Diagnosis — Prog- nosis — Treatment 365. CHAPTER XXXVII. Diseases of the Salivary Gl.ands. Inflammation of the Parotid Gland — Symptoms and Diagnosis — Prognosis — Treatment. Salivary Calculi — Causes — Symptoms — Diagnosis — Treatment. Salivary Fistula — Causes — Diagnosis — Treatment 371 CHAPTER XXXVIII. Neuralgia. Definition. Causes. Predisposing Causes. Exciting Causes. Trifacial Neuralgia — Symptoms — Causes — Diagnosis 37^ CHAPTER XXXIX. Treatment of Trifacial Neuralgia. Therapeutic Treatment — Surgical Treatment 391 CHAPTER XL. Congenital Fissures of the Lip and the Vault of the Mouth. Origin — Non-Union of Superior and Lateral Processes — Arrested Develop- ment — Faulty Nutrition — Heredity — Maternal Impressions. Prognosis 400 XIV CONTENTS. CHAPTER XLI. Congenital Fissures of the Lip and the Vault of the Mouth. (Continued.) PAGE Surgical Treatment — Operations. Hare-Lip — Uranorrhaphy — Staphylor- rhaphy — Mechanical Treatment 411 CHAPTER XLH. Tumors. Definition. Origin. Germinal Layers. Structure. Classification 429 CHAPTER XLIIL Tumors of the Face, Mouth, and Jaws. Epithelial Tumors. Papillomata — Definition. Cornu Cutaneum — Treat- ment 442 CHAPTER XLIV. Epithelial Tumors (Continued). Adenomata — Definition — Causes. Adenoma of the Skin — Diagnosis and Symptoms. Adenoma of the Palate — Diagnosis and Symptoms — Prog- nosis — Treatment. Adenoma of the Tongue — Diagnosis and Symptoms — Prognosis — Treatment. Adenoma of the Salivary Glands — Diagnosis and Symptoms — Prognosis — Treatment 453 CHAPTER XLV. Cystomata. Definition. Cysts of the Jaws and Teeth — Diagnosis — Prognosis — Treat- ment 470 CHAPTER XLVI. Cystomata (Continued). Multilocular Cysts of the Jaws — Definition — Causes — Diagnosis and Symp- toms — Prognosis — Treatment 480 CHAPTER XLVII. Cystom.\ta (Continued). Dentigerous Cysts — Causes. Dermoid Cysts. Diagnosis and Symptoms. Differential Diagnosis. Prognosis. Treatment 488 CHAPTER XLVIIL Carcinomata. Definition. Origin. Varieties and Structure. Squamous-Celled— Cylin- drical-Celled— Glandular. Infection and Dissemination. Prevalence. Sex. Age 503 CONTENTS. XV CHAPTER XLIX. Carcinomata (Continued). ^ ' PAGE Causes — Heredity — Bacteria. Exciting Causes. Diagnosis and Symptoms. Prognosis. Treatment 520 CHAPTER L. Carcinomata (Continued). Carcinoma o£ tlie Sl; 1250. spore, and when the latter reaches its full development, gelatinous softening of the cell-membrane takes place, the cell breaks up, and the spore is set free. During the process of development of the spore into a bacillus it loses its tough enveloping membrane and is therefore more readily destroyed. The majority of bacteria grow at a temperature of 37° 0.^98° F. Spores resist the action of germicidal agents to a much greater degree than the bacilli which produce them. Mature bacteria cannot resist a temperature of y7° C, 170° F. Most of them are destroyed when exposed to 55° C, 131° F., while spores have been known to resist a temperature of 100° to 120° C, 212° to 236° F. A SURGICAL BACTERIOLOGY. I3 temperature of ioo° C, 212° F., if maintained for ten to fifteen minutes, will effectually destroy the most persistent of spores. Spores which have gained an entrance to the body may remain dormant for years, and give rise to no untoward symptoms until aroused to activity by conditions which favor their growth and devel- opment. Two conditions are necessary for the germination of bac- teria, viz : a certain amotmt of heat and moisture. Both must be pres- ent. The requisite amount of heat minus the moisture, or the moisture without the heat, are in neither case favorable to their development. This is eminently true in the treatment of dental caries and devitalized teeth ; with thorough desiccation of the cavity of decay or of the root- canal, and the prevention of the ingress of moisture, caries will be ar- rested in the one case, and suppuration prevented in the other. In no department of surgery is thorough antisepsis more important than in operations upon the teeth. The Pyogenic or Pus Microbes. — The micro-organisms with which the surgeon has most frequently to contend are those which cause suppuration. Their effect upon the inflammatory exudates, leu- cocytes, and cellular elements of the tissues, is one of specific action by which they convert them into pus-corpuscles. They are therefore called pyogenic or pus-microbes. Of these there are several varieties, most of them of the globular or coccus form. The number of bacterial forms which have been found in connection with surgical diseases, and fully identified as their exciting cause, is not large; yet the statement may be safely made upon the basis of our present knowledge, that all traumatic infective diseases can be traced to the action of micro-organ- isms which have gained an entrance to the tissues. Koch lays down certain rules as a crucial test, before the positive assertion can be made that a particular organism is the specific cause of a disease: 1st, it must be found in all cases of that disease; 2d, it must be found in no other disease; 3d, it must appear in such quantity and be so distributed that all symptoms can be accounted for by its presence; 4th, the organism must be capable of being isolated from the diseased tissues, and be grown upon some of the artificial culture- media; 5tli, when injected into an animal it must be capable of repro- ducing the disease. All of these conditions can rarely be fulfilled in many cases, yet when a certain form or variety of bacteria is constantly present in a particular disease, it is pretty good evidence that it is the cause of that disease. Infection. — The effect of infection with the pyogenic cocci will always vary with the number of the microbes entering the tissues, the favorable or unfavorable conditions of the tissues for their growth, and the general susceptibility of the organism. Tliese facts have been abundantly proved by repeated inoculation experiments upon 14 SURGERY OF THE FACE, MOUTH, AND JAWS. animals. Watson Cheyne found that the number of the bacteria in- jected makes a very great difference in the intensity of the symptoms and the character of the disease. He arrived at a general idea of the number of bacteria in a given quantity of fluid by means of the plate culture, the fluid having been diluted for the purpose; a definite quan- tity of this fluid was injected into an animal, and at the same time plates were made from an equal quantity. The number of organisms in the fluid injected was thus quite accurately determined. In the case of the Proteus vulgaris of Hauser, Fig. 14 (a bac- terium commonly associated with putrefaction), he found that a dose of i-io c.c. of an undiluted culture contained about 250,000,000 bac- teria, and when injected into the muscular tissue of a rabbit quickly proved fatal; while a dose of 1-40 c.c, containing about 56,000,000, ^^^ Bacillus Proteus Vulgaris of Hauser. X looo. caused very extensive abscess and resulted in the death of the animal in from six to eight weeks. Doses which contained less than 18,000,000 very rarely produced any effect. He also demonstrated that with cultures of the Staphylococcus pyogenes aureus it was necessary to inject a dose sufficient to include a\ least 1,000,000,000 cocci into the muscle of the rabbit to procure a speedy fatal effect; while a dose of 250,000,000 caused the formation only of a small circumscribed abscess. The Staphylococcus pyogenes albus was found to produce the same results, but with somewhat larger doses. Another interesting fact discovered by the same investigator was, SURGICAL BACTERIOLOGY. I5 that concentration of the bacterial material in a certain locality was necessary to produce the most marked results. Dividing the dose and injecting it at different times or in different locations at the same time, did not produce the same results as when it was all injected into a single locality. The susceptibility of the human organism to the action of the pyogenic cocci is hot very great, and the results produced by them will vary according to the numbers introduced and the conditions of the tissues at the time. The introduction of small numbers of these microbes, if accompanied with the toxic substances which are present in the virulent cultures, is more liable to cause suppuration than when not so accompanied, and the extent of the inflammatory process will bear a close relation to the quantity and quality of these substances. (Warren.) The entrance of a few pus-microbes into a wound may be entirely harmless unless the conditions are favorable for their growth and mul- tiplication. Such conditions would be represented by retained exuda- tions, a blood-clot, or irritation of the wound from sutures or dressings. Pathogenic micro-organisms are frequently found in the blood of healthy living persons, but it remains a disputed question as to vifhether they can exist in the body without causing disease. Experiment has proved that pathogenic micro-organisms are harmless so long as they remain in the circulating blood, but if they become localized then their specific pathogenic action becomes manifest. Pathogenic spores may remain in the healthy body for an indefinite period, in a quiescent state, or until some pathologic change takes place in the tissues, furnishing the soil and conditions for their germination. Fodor injected pathogenic bacteria into the circulation of rabbits, for the purpose of studying their effect upon the tissues and the mode of elimination. In a majority of instances he found that they had en- tirely disappeared from the blood at the end of twenty-four hours, and he is of the opinion that they were destroyed by the blood-corpuscles. Metschnikoff advanced the theory that the leucocytes, which are always present in large numbers in acute inflammatory processes, and which he denominated phagocytes, have the power of appropriating and destroying the invading bacteria. The relative frequency of the presence of pyogenic cocci in cases of suppuration in the human species is shown by Steinhaus to be as follows: Out of 330 cases reported by different observers, the staphy- lococci were present in 66.5 per cent.; the streptococci in 20.4 per cent., and a mixture of these two forms in 9.5 per cent., while the tenuis was present in only i per cent., and the other forms even more rarely. In other words, pus micro-organisms were present in 97.4 per cent, of cases. l6 SURGERY OF THE FACE, MOUTH, AND JAWS. The Staphylococcus pyogenes aureus (Fig. 15), yellow cocci, — so called from the fact that if is arranged in clusters, and gives a yellow color when cultivated in beef-gelatin, — is the most common of all the pus-microbes. It is globular in shape, and its diameter ranges from 0.7 to 0.87 micro-millimeter. The size depends upon the age of the coccus and the soil in which it grows. It multiplies by fission, but the line of division is difficult to make out. It grows readily upon beef- gelatin at the house temperature, but is more active when grown in a temperature like that of the body, and does not require a large amount of oxygen to maintain a vigorous growth. It has the power of lique- fying gelatin by virtue of its peptonizing action, and it receives the color of nearly all the staining agents very readily, and is well adapted to the Gram method. It is also very tenacious of life, and requires to be subjected to the boiling temperature for several minutes in order to Fig. 15. ^ fry VLOCOCCUS PYOGENES destroy its vitality. Cultures of this coccus have a peculiar and dis- agreeable odor like that of sour paste. It is found abundantly outside of the body. Its most common seat is the superficial layers of the skin, particularly in those parts of the body which are kept moist, like the axillae, between the buttocks, etc.; also under the free ends of the finger-nails; in the mucus of the nasal passages, pharynx, mouth, and digestive tract. It has likewise been found in the air, especially of hospital wards which were in an unsanitary condition; in garden soil, in the dirt of the streets, in dirty dish-water, and in fact almost every- where. The Staphylococcus pyogenes albus — white coccus — cannot be dis- tinguished from the aureus, except that it does not develop the yellow or golden-colored pigment. It would seem to be a variety of the aureus but for the fact that it cannot be so cultivated as to give the color of the yellow coccus. It always maintains its white color in any SURGICAL BACTERIOLOGY. 17 culture-medium upon which it will grow. It has the power of lique- fying gelatin. It is found less often than the aureus, is not so virulent, and the disturbances in the tissues caused by its presence are less pro- nounced. The Staphybcoccus viridis flavescens, — greenish-yellow coccus, — found in the vesicles of varicella, is an exceedingly rare variety. According to Babes it occupies an intermediate position between the aureus and albus. The cocci are irregular in shape, and larger than the aureus. When cultivated upon agar-agar, it forms a delicate film. Its characteristic color is a greenish-yellow pigment. The Staphylococcus pyogenes citreus — lemon-colored coccus. This variety seems to be in all respects like the aureus and albus in its behavior, with the exception that it develops a pale-yellow or lemon- yellow pigment when cultivated in beef gelatin. It liquefies gelatin more slowly than the aureus or albus. The Staphylococcus cereus albus et Havus — white and yellow cocci. These are two rare and unimportant forms. The albus is found in the pus of acute abscesses, and Tils discovered it in hydrant water. The flavus was also found in acute abscess. Passet, the discoverer, has only found them in two cases of abscess; other investigators have been unable to find them. Under the microscope they cannot be distin- guished from the other varieties. When cultivated in artificial media, they each develop their characteristic pigment, and produce a dull, waxy growth when cultivated upon the surface of gelatin plates. The Micrococcus pyogenes tenuis. This coccus obtained its name from the great delicacy of its growth. It was discovered by Rosen- bach in the pus of an abscess, and is another rare form of pyogenic coccus. It is more than probable that like the cereus it may have had onl)' an accidental presence in an abscess, and not be in any sense a pus-microbe. Under the microscope it presents a somewhat irregular shape, and is larger than the aureus. It produces a thin, transparent, varnish-like film upon the agar culture. The Streptococcus pyogenes (Fig. i6) is a very important variety of the pyogenic cocci. It is usually found alone, but occasionally it is associated with the staphylococci. The arrangement of the organism is in chains or rows, usually from six to ten being attached together. They measure in diameter about one micro-millimeter. Micro- scopically they are identical with the streptococcus of erysipelas, the only discoverable difterence being one of size, the erysipelas organism being the larger. The streptococcus grows at house temperature, but is more active at a temperature of from 30° to 37° C. On culture- media the coccus reaches its full development in from four to five da5's. It is not particularly sensitive to the absence of oxygen, but nevertheless grows best upon the surface of the gelatin. At first it has l8 SURGERY OF THE FACE, MOUTH, AND JAWS. a transparent whitish appearance, but later this color changes to a faint brown. It grows most readily in bouillon, multiplying with great rapidity. The organism is found under normal conditions in the saliva and mucous secretions of the mouth and nasal passages, in vaginal mucus, and in the urethra; it is also found as a "mixed infection" associated with the pathogenic organisms of typhoid fever, pneumonia, tuberculosis, scarlet fever, and diphtheria, and may therefore be an important agent in causing the various complications of these affec- tions. Fig. i6. *• «««» •*. 1 "SOB -• « •■»• ^^•-' ^ .• N5- *- ' ' 'p> " » >*» ^' 4 '. ":> \ ' J-. ' J>. r,^^* •* Streptococcus pyogenes. The Bacillus pyocyanetis is a widely distributed form, but not neces- sarily a pus-producing microbe. It is the organism of blue or green pus, and is found in wounds with purulent or serous discharges, in the perspiration, and in the viscera of human cadavers. It is a small, slen- der rod with distinctively rounded ends, and may occur in chains or rows, usually arranged five or six in a row. It has active motility, and SURGICAL BACTERIOLOGY. I9 produces upon gelatin a beautiful green fluorescent pigment. The pigment is formed when the organism is in contact with the oxygen, and this may be seen upon the edges of dressings and bandages. It grows readily at house temperature, and belongs to that class which will grow and multiply with a scant amount of oxygen. Spores have not been seen to form. The coloring matter produced by this organ- ism has been termed "pyocyanine." It was discovered by Bouchard that cultures of the Bacillus pyocyaneus will prevent the development of anthrax or splenic fever, if injected into the tissues of animals al- ready infected with virulent cultures of the anthrax bacillus; and that the disease could be cured by the same means even after it had devel- oped. The Bacillus pyogenes fetidus is a rare and unimportant organism found in ischiorectal abscesses. Upon gelatin cultures it forms upon the surface a white or grayish film of delicate growth. When grown upon agar or potato, it produces a light brown color and has an offen- sive odor. The Micrococcus tetragcnus is also a somewhat rare form, and was first found by Gaffky in a tuberculous cavity of a lung; it is also occa- sionally seen in both morbid and healthy expectorations. Steinhaus found it in an acute abscess near the angle of the jaw. lakowski also found it in two cases of acute abscess, one of the finger, the other in the palm of the hand. This organism is characterized by being grouped in fours and involved in a capsule, hence its name, tetragenus. In cul- ture-media the coccus does not grow in any regular order, but when found in the tissues it is always in groups of four imbedded in a gela- tinous envelope. It takes the stain of all anilin dyes, and also of the Gram method. It is an aerobic organism, and when grown upon gelatin appears as thick, globular, whitish masses with a somewhat glistening surface, but does not cause liquefaction of the gelatin. Steinhaus and others have proved by experimental research that pus may be produced without the aid of the pus-producing micro- organisms, by the introduction into the tissues of certain irritating chemical substances, but that the pus so produced was aseptic, and that inoculation with it would not produce an infectious inflammation. It was also found that injection of the chemical substances elaborated by the pyogenic cocci when separated from them would produce pus of a non-bacterial character. Practically, however, this knowledge is of little value from the clinical standpoint; as acute suppuration without the presence of the pyogenic micro-organisms in the system is never observed. Mechanical irritation or the presence of foreign bodies in the tissues cannot produce an infectious pus without the aid of micro- organisms. The power of the pyogenic cocci to produce pus lies in their ability to liquefy the fibrinous elements of the tissues and the mflammatorv exudates. (Senn.l 20 SURGERY OF THE FACE, MOUTH, AND JAWS. The presence of the pyogenic cocci is exceedingly rare in cold abscesses, and for this reason it has generally been supposed that they were only produced by the Bacillus Uibercttlosis, but Ernst and several other observers have found the Staphylococcus aureus and albus in cases of psoas abscess. The failure to obtain cultures of the pyogenic organisms in cold abscess may possibly be due to the death of the microbes as a result of the age of the abscess. Acute inflammation often immediately follows the opening of such abscesses, either from infection from the outside, or growth of latent spores previously depos- ited, and which have taken on active growth and multiplication as a result of the changed surroundings which have furnished a favorable soil for their development. REVIEW. CHAPTER I. What has the Germ Theory of disease accomplished for Medicine and Surgery? In the light of this theory, what may disease be considered? What are parasites? Are bacteria classed as animal or vegetable organisms? To what order of plants do they belong? What can be said of their size? How can they be demonstrated in the tissues? What other methods are sometimes necessary to demonstrate their presence? What forms of bacteria are the smallest? What other terms are applied to these organisms? How are these organisms classed? What is the peculiarity of an aerobic microbe? Give an example of an aerobic microbe. What is the peculiarity of the anaerobic microbe? Name an organism of this class. To which of these classes do the majority of microbes belong? What term is applied to those aerobes in which a diminution of the amount of oxygen arrests their development? What term is applied to those aerobes which can live with or without oxygen? Are the anaerobes common among the pathogenic bacteria? What is the effect of long exposure to oxygen upon certain pathogenic organisms? Under what conditions will oxygen destroy the vitality of the anthrax bacilli? What dyes are used to stain bacteria? What is the object of using staining fluids? How are tissues prepared for examination? What is the value of double staining? Give the formula for Ziehl's staining fluid. SURGICAL BACTERIOLOGY. 21 Wliat are the various functions of bacteria? How is it customary to class them in relation to disease? What are non-pathogenic bacteria? What are pathogenic bacteria? What is the function of the saprophytic germs? How do pathogenic micro-organisms produce these effects? Into what two classes are pathogenic micro-organisms divided? What is the basis upon which further subdivision is made? What is a micrococcus? How are these organisms arranged? When are they termed staphylococci? When are they termed diplococci? When are they termed streptococci? What is the form of the bacillus of tetanus? What is the form of the bacillus of cholera? What is the form of the Bacterium lactis? What is the form of the Leptothrix buccalis? What is the difference between the streptococcus of pus and the strepto- coccus of erysipelas? By what process do the cocci multiply? Where are the cocci generally found? What is a bacillus? What forms of bacteria are not classed as bacilli? What is a spirillum? Give examples of this form of bacteria. What are the characteristics of bacilli? How do they multiply? What is endogenous spore formation? How long does it take for segmentation to take place in a coccus? What structure protects the spores from deleterious external influences? Describe the process of liberating the spore. What becomes of the enveloping membrane during the development of the spore into a bacillus? Which are more resistant to germicidal agents, spores or bacilli? What is the temperature which cannot be resisted by a mature bacillus? At what degree are most of them destroyed? What degree will spores resist? What sometimes becomes of spores which have entered the body and do not immediately germinate? What two essentials are necessary for the germination of bacteria? What forms of bacteria does the surgeon have to contend with most fre.- quently? How do they cause suppuration? What are the causes of traumatic infectious diseases? Name the conditions which Koch applied as a test before positive assertion could be made that an organism was the specific cause of a disease. What conditions will govern infection with the pus-microbes? How does quantity affect the result? What dose is necessary to produce extensive abscesses? What is the minimum dose to produce an effect? How large a dose of the Staphylococcus pyogenes aureus is necessary to produce death in a rabbit? How large a dose to produce a circumscribed abscess? 22 SURGERY OF THE FACE, ilOUTH, AXD JAWS. What is the size of the dose and the effect when the albus is injected? What condition is necessar\' to produce the most marked results? What is the effect of divided doses? What is the effect when the toxic substances are introduced with the organisms? What conditions favor the growth of microbes in a wound? Are pathogenic organisms ever found in the blood of healthy persons? Is their presence harmful, and if so, under what conditions? What may become of spores which remain in a healthy body? What part ma}- the phagocytes play in the destruction of bacteria? In what per cent, of cases did Steinhaus find the pus cocci in suppuration? Describe the Staphylococcus pyogenes aureus. Where is it most frequently found upon the outside of the body? Where else is it found? Describe the Staphylococcus pyogenes albus. What are its effects upon the tissues as compared with the aureus? Describe the Staph3'lococcus viridis flavescens. How does it differ from the aureus and albus? Describe the Staphjdococcus pyogenes citreus. How do3S this variety differ from the aureus and albus? Describe the Staphylococcus cereus, albus et flavus. Describe the Micrococcus p}-ogenes tenuis. Describe the Streptococcus pj'ogenes. How does it resemble the streptococcus of erysipelas? Where is it found under normal conditions? With what pathologic conditions is it sometimes found? Describe the Bacillus pyocyaneus. Is it motile or non-motile? What term is applied to the coloring matter produced by this organism ? What effect has injection of cultures of this organism over anthrax? Describe the Bacillus pyogenes fetidus. Describe the ^^licrococcus tetragenus. How is it distinguished from other micrococci? How may pus be produced without the presence of pyogenic bacteria? What is the eft'ect of the injection into the tissues of the chemical sub- stances elaborated by the pyogenic cocci? Does acute suppuration occur without the presence of the pyogenic cocci? How do the pyogenic cocci produce pus? Are the}' found in cold abscesses? How is the fact that thej' are rarely so found accounted for? CHAPTER II. SURGICAL BACTERIOLOGY (Continued). The subject of Surgical Bacteriology would be very incomplete if the pyogenic organisms were the only forms considered in these pages. Prominent as they are in all surgical practice, they are never- theless much more amenable to treatment by antiseptics, and far less dangerous to the life of the patient than some of the forms to be men- tioned later. The interest of the surgeon is largely taken up with the prevention of suppuration following injury and surgical operations, but there are several diseases due to the presence of micro-organisms which sometimes present very grave and alarming symptoms, and which the surgeon must be prepared to combat. There can be no better preparation for such a battle than a knowledge of the character, number, and fighting qualities of the enemy, his base of supplies, the strong and weak points in his line of battle, and the number of his efficient reserves. The science of bacteriology furnishes this knowl- edge to the surgeon. The Bacillus coli communis (Fig. 17) is constantly found in the dis- charges of healthy and unhealthy persons. It was first found in the discharges of cholera patients at Naples. It is also found outside the body in the air, in water, and in putrefying fluids. The importance of this organism has recently been augmented by its recognition as a cause of septic and suppurative processes in the peritoneal cavity. This bacillus is usually seen as a short rod with rounded ends; it most frequently forms in pairs, but it may be combined in chains of from four to six filaments. Occasionally both of these forms are asso- ciated together, which may lead to a mistake, as the appearance is that of a mixed culture. The organism possesses numerous and peculiar cilia. Spores have not been demonstrated. It stains readily with the anilin dyes, but is decolorized with iodin. It grows freely upon acid or alkaline media, with or without the presence of oxygen; the pro- ducts of its growth are acid, and it does not liquefy gelatin. On gelatin plates it has two forms of growth: One is an irregular film, rapidly spreading over the plate, and having an opalescent color, while the other is an ivory-white, heaped-up colony, which shows no ten- dency to spread. Under favoring circumstances other bacteria like 23 24 SURGERY OF THE FACE, MOUTH, AND JAWS. the typhoid bacillus and the pneumococcus may assume pyogenic qualities. Fig. 17. "** »^ > til .^ -^' .«k l\lb. \ *--J. ^'^ \ 4 i^* t"'*.-**'<. ■ Bacilli's coli communis. X 1200. The Streptococcus erysipclatus (Fig. i8) so closely resembles the Streptococcus pyogenes that it is almost impossible to distinguish be- Streptococcus erysipelatus. tween them, the only physical difference discoverable being one of size, the erysipelatus coccus being the larger. (Rosenbach.) The consensus SURGICAL BACTERIOLOGY. 25 of opinion, however, is in favor of their identity; for the reason that the majority of bacteriologists are unable to detect any differences which are constant between them. The description of this organism is the same as for the Strepto- coccus pyogenes. It is without doubt the cause of erysipelas, and perhaps of puerperal fever, for there is a very close relationship exist- ing between these conditions, as many medical men have learned by sad experience. Experimental research has discovered that culti- vations of the streptococcus from puerperal cases injected into rabbits produced erysipelas. Fig. 19. GONOCOCCUS. The infection of old ulcers with the virus of erysipelas has often proved curative, and cases are on record in which tumors have disap- peared during an attack of erysipelas. Cultures of the organism have been used frequently of late in the treatment of inoperable neoplasms, particularly sarcomas, with varying success. The Gonococais (Fig. 19) is the specific micro-organism which pro- duces gonorrhea. It is found in gonorrheal pus, generally in the form of a diplococcus, and measures 1.25 micro-millimeters in diameter. It is exceedingly difficult to cultivate, only growing upon blood-serum at a temperature of 33° to 37° C, and not in company with other organisms. One of its marked peculiarities is the power which it possesses to enter other cells, and grow and multiply within them. This peculiarity differentiates it from nearly all other forms of micro- cocci. It is rare to find a gonococcus outside of a pus-cell. Some- times the cell becomes so filled with them as to lose all of its character- istics and assume the appearance of a cluster of diplococci. The 26 SURGERY OF THE FACE, MOUTH, AND JAWS. gonococcus stains well with inethyl blue, but not with the Gram method. Neisser recommends double staining with eosin and methyl blue. Its growth upon blood-serum produces a thin, varnish-like film with irregular but sharply defined edges; later it becomes grayish white, and afterward a slightly brownish hue. The gonococcus is only found associated with certain mucous membranes, — those which possess a cylinder epithelium, or one closely allied to it, like the mem- FlG. 20. Tetanus (Shows Smear ot Culture-Medium ) X i2co. brands of the male and female urethra, vagina, uterus, and conjunctiva. Why it should grow in these particular membranes and only in their superficial layers, and nowhere else in the body, is still unexplained. The Bacillus tetani (Fig. 20) is a large slender rod with rounded ends, — one end being enlarged, giving it the appearance of a round- headed pin or a drum-stick. It is motile, and belongs to the anaerobic class of micro-organisms. Exposure to the air quickly destroys its vitality. It sometimes grows in long chains, the divisions being im- perfectly seen. The enlargement at the end is due to the formation of SURGICAL BACTERIOLOGY. 27 a spore. The spore germinates in thirty hours if kept at a temperature of 37.5° C, while if kept at the house temperature it requires about one week. It is readily colored by methyl blue and fuchsin, the Gram method being especially adapted to bring it out to perfection. It can be grown in cultures of gelatin mixed with grape sugar; the latter aids its rapid development. Being a strictly anaerobic microbe, it does not grow when exposed to the atmosphere, and this accounts for the fact that the surface of the gelatin inoculated with the bacillus remains sterile; while at the bottom of the culture there is active growth, send- ing out innumerable slender prolongations, and producing in the gela- tin the appearance of an inverted fir tree. At the end of a week the Fig. 21. gelatin begins to liquefy, and soon the whole mass is changed into a light gray, tenacious, shining substance. The spores have been found in garden soil, in masonry, in the dust of the streets, in decomposing liquids, and in stable manure. Hence the frequency of tetanus among gardeners and stable men. Tetanus is thought to be produced by the elaboration of certain toxic sub- stances from the bacillus which are taken up by the circulation, and cause irritation of the nerve-centers. Brieger obtained three toxic substances from cultures of the bacillus, which he named "tetanin," "tetanotoxin," and "spasmotoxin." All of these, when injected into animals, caused spasms or convulsive movements, and finally paralysis. The Bacillus tuberculosis (Fig. 21) is a small, slender rod, varying in length from one-fourth to three-fourths the diameter of a red blood- corpuscle. It has rounded ends, and is somewhat bent or curved near 28 SURGERY OF THE FACE, MOUTH, AND JAU'S. the center; is usuall)' single, sometimes arranged in pairs, and often in the form of a letter V, or strung together. The longest rods are usually seen in the sputa of phthisical patients. This bacillus does not possess motile power. It is thought by Baumgarten that it multiplies by endogenous spore formation, from the fact that the cheesy material of a tubercle in which no bacilli can be discovered by any method of staining, if injected into animals, produces the disease. The bacilli have never been seen in the process of spore formation, and free spores have never been discovered. These bacilli are very tenacious of life; sputum charged with them may be kept for months and even years in a dried state without endangering their vitality. They also possess great resistive power to the acids of the stomach and to the products of decomposition; they may even pass through the entire alimentary tract without in any way impairing their vitality. This resistance is due to the unusually tough enveloping membrane or cell-wall possessed by the bacillus. It requires the boiling temperature for twenty minutes to destroy the organisms in tuberculous sputa. The tubercle bacillus is a facultative anaerobic microbe, — grows with or without oxygen, but flourishes best in the atmosphere. It is among the most difficult of the bacteria to stain with the anilin dyes, and like the bacillus of leprosy, which it greatly resembles, does not readily yield to the action of bleaching agents. Nearly all other bacterial forms are readily decolor- ized. The bacilli are found in the tubercles, between the leucocytes in the epithelioid cells, and in the giant cells. This organism is exceedingly difficult to cultivate, though it grows upon the hardened blood-serum of Koch, or upon a combination of agar and glycerol, but it requires from twenty-one to twenty-eight days when hardened blood-serum is used, which indicates a predilec- tion of the bacillus for glycerol. At the end of this time the culture appears as thick, dull, grayish-white scales, very dry and brittle. Material for cultures is obtained by inoculating guinea-pigs with tuberculous sputa. When the disease is established the animal is killed, and fragments of tubercle from the lungs are placed upon the culture-medium. The tubercle bacilli are never found growing outside of the living tissues of man and animals, as the proper conditions of nutrition and temperature can nowhere else be found; they are therefore true animal parasites. Inoculation may occur through abrasions of the skin, through the mucous membrane of the respiratory tract or digestive system. Ernst has shown that six drops of milk from a tuberculous cow injected under the skin of a guinea-pig may develop tuberculosis. The Bacillus mallei, Figs. 22, 23 (bacillus of glanders), is a short, straight rod; in length about two-thirds the diameter of a red blood- corpuscle, — that is, somewhat shorter and a trifle thicker than the SURGICAL BACTERIOLOGY. 29 tubercle bacillus. They are generally found single, but are sometimes arranged in couples, side by side. In the tissues they are grouped in ■clusters, either parallel with one another or at various angles. In •culture-media several of them may be joined together in chains. Thev are non-motile, and belong to the facultative anaerobic organ- 30 SURGERY OF THE FACE, MOUTH, AND JAWS. isms. This bacillus was discovered by Loffler and Schiitz, who suc- ceeded in demonstrating its presence in the tissues, cultivated it outside the living organism, and produced the disease by inoculation of ani- mals with the culture. The animals in which the virus can be readily inoculated are the horse, the ass, goats, cats, field mice, and guinea- pigs. Lions and tigers have also been successfully inoculated with it. Pigs, white mice, house mice, and oxen are not susceptible to the dis- ease. Man frequently becomes inoculated through abrasions upon the hands, etc. Post-mortem examinations reveal nodules in the spleen, liver, and lungs which in many respects resemble the tubercle nodule. The bacilli are found most plentifully in the center of the nodule, and generally lying between the cells. Epithelioid cells and leucocytes make up the bulk of the nodule; giant cells are never present. The secretions from the nasal passages have few bacilli in them. The organism is readily stained and as readily decolorized. It grows readily upon a 4 per cent, glycerol-agar, and upon potato. The potato culture produces around the border a yellowish-green color, which would seem to be pathognomonic, as no other organism gives this color under cultivation. It grows best at a temperature of 37° C. The Bacillus of Malignant Edema is a saprophytic organism. It is- a slender rod, narrower than the anthrax bacillus, for which it is some- times mistaken; frequently arranged in bands, which are often bent or curved. They are strictly anaerobic, and are endowed with active motility. Motion soon ceases on their coming in contact with oxygen, as they are exceedingly sensitive to even the slightest trace of it. Spores are formed in a temperature above 20° C. ; these are large, and may be situated at the center or the end of the rod. They stain well with the anilin dyes, but not by the Gram method. When stained the ends of the rods appear pointed, which distinguishes them from the anthrax bacillus. They grow best in gelatin cultures to which from I to 2 per cent, of grape-sugar has been added. They liquefy gelatin, and usually form gas which distends the needle tract and gives- off an offensive odor peculiar to ptitrefaction. The bacillus is found in decomposing substances, in dirty water,. in the dust of the streets, and in rich garden-mold; being found in greatest abundance in the latter. Injections of garden soil are more virulent than the pure culture of the bacillus, and when introduced subcutaneously in the guinea-pig, produce a progressive emphysem- atous gangrene similar to that seen in man. The organism is occasioH- ally found in cases of traumatic gangrene in man, but always in the superficial tissues and never in the blood-vessels, in marked contrast tO' the habit of the anthrax bacillus. According to Chauveau, animals which have recovered from an attack of malignant edema are rendered immune to the disease ever afterward. SURGICAL BACTERIOLOGY. 3I The ''psetido-edevia" bacillus is distinguished from the bacillus of malignant edema by its thicker form, the possession of a very bright border, and by the formation of two spores in each rod. It is strictly an aerobic organism, and not so infectious as the true bacillus. In cultures it is accompanied by an abundant gas-formation which has the odor of old cheese. It is sometimes found in traumatic gangrene of man. Noma, a malignant gangrenous inflammation of the mouth and genitals in young children, is probably caused in many cases by the bacteria of this class, which with the pyogenic cocci are always present and ready to attack wounds located in uncleanly parts of the body, and in the tissues whose vitality has been impaired or destroyed by injury. The Bacillus of Leprosy. This bacillus in appearance is almost identical with the tubercle bacillus and the glanders bacillus. It is a Fig. 24. V' '-v '' F Leprosy. X 1000. long, slender rod, with sharpened ends, is non-motile, and is the only organism which reacts to the coloring reagents in the same manner as the tubercle bacilli. (Fig. 24.) The readiness with which it takes the anilin dyes, and also stains by the Gram method, distinguishes it from the tubercle bacilli. Bacteriologists have not as yet settled the question as to its being the actual cause of leprosy. The bacilli of leprosy are usually found in the skin and the tissues immediately surrounding the nerves; in the lymphatic glands, the spleen and liver, but rarely in the blood. They grow in clusters, usually inside of the cells— leucocytes and epithelioid cells, which in consequence have been called lepra cells. 32 SURGERY OF THE FACE, MOUTH, AND JAWS. The Bacillus of Syphilis. The microbic origin of syphihs has at- tracted the attention of bacteriologists generally, but so far the specific organism of the afifection has not been conceded. The clinical features of the disease make its microbic origin almost certain, and that the organism is a bacillus, but it has not been satisfactorily demonstrated. Lustgarten announced in 1884 the discovery of an "S" shaped bacillus in the tissues and discharges of syphilitic ulcers which closely resem- bled the tubercle bacillus, but he was unable to successfully cultivate it. It was distinguishable from other forms by the peculiar methods necessary to stain it. Gelatin made from the bladders of Russian stur- geon is said to be a medium upon which it may be successfully culti- vated. Doubt has been thrown upon Lustgarten's discovery through the simultaneous finding by two different observers of a similar bacillus in the preputial and vulvar smegma. Eve and Lingard cultivated a bacillus which they found in the blood and tissues of syphilitic patients, and describe it as resembling the tubercle bacillus. It was readily stained by the ordinary anilin dyes and by the Gram method, but would not take the stain by Lustgarten's method. Pure cultures were obtained, but inoculation of monkeys with these gave negative results. Disse and Taguchi found an almost constant "coccus" in patients suf- fering from secondary syphilis. The organism was found isolated or in groups between the corpuscles. Inoculation with pure cultures, in rab- bits, dogs, and sheep, produced a chronic infectious disease, which was transmitted to the offspring. Martineau and Hammic succeeded in producing eruptions in mon- keys resembling those of syphilis, and nodules which simulated indu- rated chancre, by inoculating these animals with a culture bouillon in which fragments of chancres had been placed, and in which the growth of bacilli had been demonstrated. Secondary symptoms were also developed. Klebs successfully inoculated monkeys in the same man- ner. Mucous patches were developed upon the buccal mucous mem- brane, and caseous deposits were found in the dura mater which resem- bled gummata. Implantation of a fragment of chancre under the skin resulted in caseous deposits, resembling the deposits of tubercle. The evidence seems therefore to favor Lustgarten's bacillus as the specific cause of the disease. The Bacillus Anthracis is the organism which produces anthrax, or splenic fever in animals. It is classed among the surgical bacteria, be- cause inoculation with the virus in man produces malignant pustule, and this frequently happens to those who have to deal with animals suffering from the malady, or who handle the hides or wool of such animals; hence the name "wool-sorters' disease." It also deserves to be so classed on account of its position historically, for it was the first of the bacterial forms discovered in the blood and tissues, and the first to SURGICAL BACTERIOLOGY. 33 be demonstrated, experimentally, as the specific cause of a disease. Upon the investigations which proved this microbe to be the real and only cause of splenic fever, the whole science of bacteriology has since been reared. The bacillus of anthrax (Fig. 25) is a large rod, from three to six micro-millimeters in length, and 1.5 micro-millimeters in thickness. When grown upon culture-media they appear as bright, transparent rods, with slightly rounded ends, and are entirely devoid of motion. The bacilli taken from the blood of animals which have recently died of anthrax appear somewhat larger at each end than in the center, and are joined together in the form of a chain, simulating the articulation of the phalangeal bones. This form of enlarged ends and articulation of the Fig. 25. rods is peculiar to the anthrax bacillus, and differentiates it from all other forms of bacteria. The spores when forming are seen as bright, glistening spots in the center of the bacilli. The developed organisms are rather delicate, but the spores are among the most resistant to ex- ternal influences, and are therefore commonly used as a test of the value of germicides. The bacilli can be cultivated in bouillon, agar, gelatin, or potato, and in human urine freely exposed to the air. Oxygen is necessary to their growth, and they grow best at a tempera- ture of 37° C. They will not grow at a lower temperature than 16° C, or at a liigher temperature than 45° C. ; the spores will not germinate without a large supply of oxygen or below a temperature of 24° C. Pasteur succeeded in producing an attenuated virus by long cultivation or cultivation carried on at high temperature, which 4 34 SURGERY OF THE FACE, MOUTH, AND JAWS. by repeated injections rendered animals immune to the disease for a certain time — about a 3'ear — through all avenues of infection except the intestinal canal. The spores are taken into the stomach with food that has been contaminated by other diseased cattle, from nasal dis- charges, urine, and feces. Oxen and sheep are particularly susceptible to infection through the alimentary mucous membrane, and as this is the most common avenue of infection in cattle, further experiment will be necessary to determine the possibility of devising a practical method of protection from the disease bv "vaccination." The Ray-Fungus. (Actiko.myces.) (After Ponfick.) Actinomyces is a ray-bacterium or a ray-fungus, which produces a disease in cattle, pigs, etc., known as Actinomycosis, or lumpy- jaw (Fig. 26). This bacterium is classed with the surgical bacteria because the disease occasionally occurs in man as a result of infection. The organism occurs in the form of spirally curved branching threads, radiating from a common center, and terminating in bulbed extremi- ties. These prolongations are so arranged as to look something like a sunflower. The bacterium macroscopically appears about the size of SURGICAL BACTERIOLOGY. 35 a millet-seed, yellowish in color, and of a tallowy consistence. It can be cultivated upon blood-serum, agar, or gelatin, and the temperatures in which its growth is most active are from 33° to 37° C. Development is completed in from five to six days. (Fig. 27.) Actinomycosis in man is an exceedingly rare affection, but one that can be diagnosed with great readiness on account of the peculiar character of the micro-orsanism. Fig. 27. Actinomycosis (Ray-Fungus) of Glands. X 500. : Action of Bacteria. — The question of Iwzv bacteria act upon the liz'ing tissues of the body is not yet fully decided. Some are of the opinion that the symptoms of infectious disease are the result of the formation by the bacteria of chemical substances of an irritating or poisonous nature, a sort of specific excreta. Others suppose the phe- nomena, both local and constitutional, to be due to changes brought about in the tissues by the organisms themselves, during their develop- ment, and that it is not necessary to assume the formation of a specific poison or virus. The action of the pyogenic bacteria locally is to produce irritation or inflammation; while the chemical substances elaborated are dissem- inated throughout the body, which by virtue of a peculiar action — thought to be ferment-like — augments tissue-metamorphosis, stimu- lates the "thermic centers," and thereby increases the body tempera- ture, producing fever or systemic disturbance. This condition is known as septic infection. 36 SURGERY OF THE FACE, MOUTH, AND JAWS. The absorption of ptomaines without the presence of bacteria will produce grave systemic disturbances. This condition would be termed septic intoxication, or toxic infection. Ptomaines, which are powerful animal poisons, are developed by the process of decomposition of animal tissue in the presence of sapro- phytic bacteria. In their physiological action they resemble the alka- loids, and when received into the circulation by the process of absorp- tion, they produce more or less severe constitutional symptoms. The "toxines" probabl)' belong to this class of substances. The develop- ment of these substances — ptomaines — appears to exert a controlling inhibitory effect upon the micro-organisms. Many of the artificial cultures of the bacteria, after a period of growth, cease to develop, and it is by virtue of the formation of these substances that this controlling effect is brought about. Leucomaines are animal alkaloids, which are produced in the tis- sues by metabolism (tissue changes), independent of micro-organisms. Their pathologic significance is as yet not well defined. The effect of the virus of certain bacteria upon the vital fluids and the tissues of the body in certain diseases is to give protection against future attacks, — in other words, to render the organism immime. Pasteur thought this protection or immunity to be due to the ex- haustion of the chemical substances (supposedl)') necessary to main- tain the life and development of the specific bacteria. Fraenkel was of the opinion that the first invasion of the bacteria left behind certain substances which were inimical to the further development of the same species of micro-organism, which might at some other time gain an entrance to the system. The direct transmission of bacterial diseases from parents to fetus is a question which has not yet been satisfactorily proved, and is hardly susceptible of a ready demonstration, though the best authorities have admitted for a long time, from clinical proofs, that many infectious sur- gical diseases are hereditary. The avenues through which hereditary diseases may be communicated are the semen, and the placenta during intra-uterine life. It is well known that syphilis may be transmitted both through the semen and the placenta; although the bacteriologic proofs are lacking as to the existence of a specific syphilis bacillus. Infection through the placenta has been frequently observed in ani- mals; "glanders has been transmitted from mare to foal, and the bacilli of anthrax, glanders, and malignant edema have been shown by experiment to pass through the placenta to the fetus." (American Text-Book of Surgery.) The best of clinical evidence exists that diseases like smallpox, typhoid fever, intermittent fever, erysipelas, measles, and scarlatina are directly transmissible from mother to fetus. Several well-authenticated SURGICAL BACTERIOLOGY. 37 cases are on record in which these diseases occurred in new-born chil- dren, and the lack of an incubation period for the disease can only be explained upon the hypothesis of pre-natal infection. The tubercle bacillus has been found in the testicles and in the prostate gland, and "it requires no stretch of the imagination to un- derstand how the spermatozoon in the testicle or on its way to the vesiculas seminalis can be contaminated with bacilli and the disease thus ti'ansmitted from father to fetus." (Senn.) The Fallopian tubes are often the seat of tuberculous disease, which makes it more than probable that the ovum in its passage to the uterus may become infected with the bacillus. The General Principles of Antiseptic Treatment. —Inasmuch as all suppurative processes are the result of the action of micro-organ- isms, which enter the system through some break in the continuity of the surface, and cause putrefaction of the tissues and exudates, the first duty of the surgeon or dentist is to prevent putrefaction, and if it has already been established, to arrest its further progress. This may be accomplished: First, By excluding all organisms from the wound, by strict attention to the details of surgical cleanliness; Second, By removing the organisms zvhich may already have gained an entrance to the zwund, by thorough irrigation before they can produce their harmful effects ; Third, By destroying the organisms which may remain, with solutions of bichlorid of mercury, or other germicides; Fourth, By removing dead and dying tissue, and establishing free drain- age, for the escape of the discharges. Disorganized tissue is the soil in which micro-organisms best grow and flourish; Fifth, By preventing the formation of a favorable soil in which they can grozv. This can best be accomplished by avoiding unnecessary manipulation of the wound, guarding against tension from stitches or bandages, and by careful, dry antiseptic dressings. Dry dressings are not applicable in wounds within the mouth, vagina, or anus. In these cases dependence must be placed upon free irrigation, with antiseptic solutions. A wound is called aseptic when it is free from pathogenic or septic micro-organisms, and septic when it is the seat of infection. The term Antiseptic means germ-destroying. Asepsis can only be secured by antisepsis. An aseptic wound is therefore one which is free from germs, or has been rendered germ free by antiseptic treat- ment. An antiseptic dressing is one which has been rendered sterile, and contains germ-destroying substances. An aseptic dressing is one which has been made germ free by sterilizing with heat. The common antiseptic solutions are carbolic acid, 3 to 5 per cent.; 38 SURGERY OF THE FACE, MOUTH, AND JAWS. bichlorid of mercury, i part to 5000, or i to 2000, i to 1000, i to 500 of water; a saturated solution of boric acid; Thiersch's solution 12 parts boric acid, four parts salicylic acid to 1000 of water. Listerine and borolyptol are also valuable antiseptics, especially for use in the mouth, but are too expensive for common use. Pulverized boric acid and iodoform are the remedies generally used in dry dressing of wounds. On account of the disagreeable odor of iodoform, boric acid has the preference with many surgeons. Vari- ous other antiseptics might be mentioned, but these are the ones in most common use. REVIEW. CHAPTER II. Describe the Bacillus coli communis. Where is it commonly found? What is the importance of this organism? Describe the Streptococcus erysipelatus. Is there any doubt as to the specific action of the organism? Has the organism any curative value in other diseases? Describe the Gonococcus. What is a marked characteristic of this organism? Where is the organism found? Why does it select this form of nmcous membrane? Describe the Bacillus tetani. How does oxygen affect it? Where are the spores found? What class of individuals are most likely to be affected by the organism? Hovf is tetanus produced? Describe the Bacillus tuberculosis. How does it multiply? How long may it live in the dried state? What other resistive powers dees it possess? What temperature will it resist, and for how long? Where are the bacilli found in the tissues? Are they ever found growing outside the tissues? Through what avenues do the organisms gain access to the tissues? Describe the Bacillus mallei. What animals are susceptible to glanders by inoculation? What animals are not susceptible to the disease by inoculation? How may man become inoculated? How do the nodules found in glanders resemble those of tuberculosis? Where are the bacilli of glanders found? Under what conditions does infection occur in man? Describe the bacillus of malignant edema. SURGICAL BACTERIOLOGY. 39 How is it distinguislied from tlie antlirax bacillus? Where is the bacillus of malignant edema found? Under what conditions is it found in man? Does one attack give immunity? How may the "pseudo-edema" bacillus be distinguished from the real organism? Under what circumstances is it found in man? What is noma? What is the probable cause? Describe the bacillus of leprosy. What characteristic distinguishes it from the tubercle bacillus? Is the bacillus the actual cause of the disease? \Miere is it usually found? Has the bacillus of syphilis been found? What would the clinical features of the disease indicate? Who discovered the "S" shaped bacillus, and in what year? What has thrown doubt upon Lustgarten's discovery? What well-known form does the S-shaped bacillus resemble? What result followed inoculation of monkeys with cultures made from pieces of chancre in which the bacilli were demonstrated to be present? What would these results seem to.indicate? What is the Bacillus anthracis? Why is it classed as a surgical bacterium? What is its historic position? Describe the bacillus of anthrax. How did Pasteur render animals immune to the disease? How long did this immunity last? ■ Through what avenue of infection did it not protect the animal? What avenue of infection is most common in cattle? What is Actinomycosis? What common term is applied to this disease? Why is this bacterium classed with the surgical bacteria? Describe the organism. How does it appear macroscopically? Is there any difficulty in its diagnosis? What are the opinions as to how bacteria act upon the bony tissues? How do the pyogenic bacteria produce their effects? What form of infection is this termed? What is the condition produced by the absorption of ptomaines, without the presence of bacteria? What are ptomaines? How are they elaborated? What do they resemble in their physiological action? How are the "toxines" classed? What effect do the ptomaines have upon the bacteria? What are Leucomaines? How are they elaborated? What is their pathologic significance? What is the effect of the virus of certain bacteria upon the fluids and tissues of the body? How did Pasteur explain this? What was Fraenkel's opinion? 40 SURGERY OF THE FACE, MOUTH, AND JAWS. What are the opinions as to the hereditary transmission of infectious surgical diseases? Through what avenues does infection take place? Are there any bacteriologic proofs that syphilis is so transmitted? Are there clinical proofs that such diseases are so transmitted? What evidence is there that other infectious diseases are so transmitted? What are the causes of all suppurative processes? How may putrefaction be prevented? First? — Second? — Third? — Fourth? — Fifth? When is a wound called aseptic? When is it called septic? What does the term antiseptic mean? By what means can asepsis be secured? What is an antiseptic dressing? What is an aseptic dressing? Name the common antiseptic solutions. What is the formula of the Thiersch solution? Why is boric acid preferred to iodoform? CHAPTER III. INFLAMMATION. A KNOWLEDGE of surgical pathology presupposes an under- standing of the process of inflammation; in fact, a correct appreciation of the various phenomena of inflammation is absolutely essential as a foundation upon which to build a correct knowledge of surgical pathol- ogy. It is therefore of the utmost importance that the student make himself thoroughly familiar with the entire subject of inflammation, for upon this knowledge, and the ability to apply it, will depend in verj' large measure the success or failure of the practitioner in any depart- ment of surgery. To Cohnheim belongs the honor of first placing before the world a scientific explanation of the phenomena of inflammation, by the pub- lication in 1867 of the results of his stud_v and experiments upon the circulation of the blood and the action of the white blood-corpuscles, as observed in inflammation. These labors added very greatly to the then existing knowledge of the inflammatory process in the tissues, and have since formed the basis for all further research in this direction. Cohnheim's views, however, have not been adopted in their entirety, as various modifications have been suggested by other investigators, but in the main they form the prevailing theory of to-day. Inflammation. — Synonym, Lat. inflmiunatio (from hiflautinare, to inflame. — Iniiavmio, I set on fire). Deftnitioii. — Inflammation is a condition of nutritive disturbance, characterized by hyperemia, with proliferation of the cells of a tissue or organ, and attended by one or more of the symptoms of pain, heat, swelling, discoloration, and disordered function. Inflammation is a series of changes in a part, identical with those which are produced in the same part by injury from a chemical or physical irritant. Pliysical Signs. — The physical signs or cardinal symptoms of in- flammation, as described by Celsns, are four in number, viz: Rubor, Tumor, Calor, and Dolor, — redness, swelling, heat, pain ; a fifth symp- tom has since been added, viz: Functio Lccsa, disturbance of function in the part. All forms of inflammation are the result of the action of certain 41 42 SURGERY OF THE FACE, MOUTH, AND JAWS. irritants. Irritants are classed under the four following heads: me- chanical, chemical, septic, and nervous. A mechanical irritant produces irritation through its mechanical action. Examples: Foreign bodies, scarification, puncture, acupres- sure, etc. A chemical irritant is a substance which irritates b}' virtue of its chemical reaction upon the tissue elements to which it is applied. Ex- amples: Alkalies, acids, croton oil, cantharides. Other examples are found in drugs which have a predilection for certain organs, and which, if administered in poisonous closes, will cause inflammation. Mercury acting upon the tissues of the mouth and salivary glands, produces stomatitis, and salivation. Cantharides will cause irritation of the urinary organs, ergot of the uterus, and uric acid will cause gouty inflammations. The toxic inflammation caused by the poison of serpents' and insects, the poisonous action of certain plants like ivy, and the ptomaines, are examples of other groups of chemical irritants. A septic irritant is a living organism, — a parasite, a micro-organ- ism, — causing irritation by its presence, and the formation of poisons, — ptomaines, — as waste products, and their introduction into the sys- tem. The pus-microbes and the saprophytic germs belong to this class. A nervous irritant is one which produces irritation through the medium of the nervous system. The influence exerted by the nervous system over the functions of nutrition, both generally and locally, and in the production of inflammatory symptoms, has long been recog- nized. Impairment of the nutrition of the skin is sometimes observed to follow injury of the nerves supplying the part. Reflex conditions are also recognized as productive of inflammation. An instance in point is irritation of the dental pulp, which sometimes occurs in preg- nant women. Herpes zoster is an example of a pustular eruption fol- lowing the course of a nerve, and is accompanied with infiltration of leucocytes, both around the terminal branches and the trunk of the nerve. (Warren.) Irritation. — Definition: To excite, to stir up, to inflame. Irri- tation is the state of a tissue or an organ in which there is an excess of vital movement, commonly manifested by increase of the circulation and the sensibility. Irritation in some form always precedes inflamma- tion, or, in other words, inflammation is always caused by some form of irritation. When the irritation is confined to a particular portion of the body, it is termed local irritation. Examples would be, an injury upon the surface of the body; infection from a devitalized tooth-pulp, etc. When the irritation affects the whole system, it is termed general or constitutional irritation. Examples would be the presence of malarial poison in the blood, or pyemia. INFLAMMATION. 43 Inflammation is a process which may affect any tissue of the body having a vascular circulation, or which is connected with blood-vessels. It begins usually with the phenomena of hyperemia, and progresses to exudation or suppuration, sometimes healing, sometimes leading to the production of new formations, or to metamorphoses of various kinds, or to death and destruction of tissue, and creating a more or less seri- ous disturbance of the functions of the parts. The disease may vary very greatly in its character and in its location. The histologic char- acter of inflammations depends upon two factors: the nature of the exudation and the changes in the tissues. Both are used to classify the various forms of inflammation, according as the one or the other seems to be the most pronounced. Hyperemia. — The condition known as hyperemia is one of the most elementary physical disturbances in the realm of surgical pathol- ogy, and occupies a position, both physiologic and pathologic, that is difficult to define. A hyperemia may be a physiologic expression of an emotion, or a local stimulation, causing an accelerated movement of the blood in a given part, or it may be the beginning of a pathologic con- dition induced by slight injury, or the entrance into the circulation of certain noxse; but just at what point the process ceases to be physio- logic and becomes a pathologic expression cannot be demonstrated. Fig. 28 shows capillary blood-vessels in a normal condition, with the blood-corpuscles passing through them. Definition: Hyperemia is a condition in which there is an in- creased amount of blood in a part. When there is an increased amount of blood in all the vessels of the body, it is termed plethora. The oppo- site conditions to these are, ischemia, a decreased flow of blood to a part, and anemia, when there is a less quantity of blood in the body than is usual. In a medical sense, the latter term is used to indicate certain pathologic conditions in the character of the blood. Hyperemia may be a physiologic or a pathologic condition. Flushing" of the cheeks, as the result of mental excitement produced by joy, shame, or anger, is an illustration of the physiologic hyper- emia; while the redness following a local irritation would more nearly express a pathologic hyperemia. Hyperemia may be divided into two forms, generally denominated active and passive; the difference between these forms being that in act- ive hyperemia there is an increase in the amount of arterial blood flow- ing into the part, while in passive hyperemia there is a slowing of the blood-current, — a partial or complete stagnation of the movement of the blood through the vessels. Local active hyperemia may be pro- duced through various forms of stimulation applied to the surface of the body, acting through the vaso-motor system of nerves, like heat, cold, mechanical pressure, rapid blows sufficient!}' light not to cause 44 SURGERY OF THE FACE, MOUTH, AND JAWS. pain, — for instance, the blows of the hand, mechanical or electric mallet in filling teeth, and the action of the faradic current. The stimu- lation by the faradic current, when applied to the surface of the body, may be likened to the mechanical stimulation of that form of massage known as hacken, — rapid and light blows made with the edges of the hands. Fig. 28. Normal Capillary Vessels : Blood-Corpuscles in them. Branched Connective- Tissue Corpuscles with Pigment. Vulpian demonstrated the vaso-motor effects upon the circulation by faradic stimulation of the peripheral segment of the lingual nerve in a dog. He found as a result of this stimulation a considerable dilata- tion of the vessels in the region of that half of the tongue to which this nerve has its distribution. The mucous membrane on the correspond- ing side of the frenum linguae of this half of the tongue also became bright red, while the principal vein became turgescent, and the blood, both in it and in its tributaries, was of bright color, like arterial blood. There was also a perceptible rise in the temperature of the part. From the experiments of Claude Bernard and others upon the INFLAMMATION. 45 ph}'sioIogic action of the vaso-motor system, it was demonstrated that section of the sympathetic nerve would produce a hyperemia of the part, through paralysis of the vaso-constrictor nerves. Stimulation oi the chorda-tympani nerve resulted in dilatation of the blood-vessels of the submaxillary gland. This served to prove the existence of two sets of nerves, one vaso-constrictors, and the other vaso-dilators, which placed the vascular system under the control of the vaso-motor centers. There is also a system of periphero-vaso-motor nerves, under the con- trol of what is known as the perivascular ganglia. The continuous action of these ganglia and of the constrictors secures a state of chronic contraction of the muscular walls of the blood-vessels. The dilators come into action only under exceptional circumstances. Strieker is of the opinion that most of the physiologic and pathologic hyper- emias are the result of irritation of the dilators. The existence of such a system of nerves and ganglia has never been positively demonstrated, either anatomically or microscopically, although microscopic clusters of ganglia have been discovered upon the arteries of the submaxillary glands, and in other locations. As hyperemia may be caused by paralysis of the constrictors, or by irritation of the dilators, two forms of active hyperemia may be recog- nized. When caused by paralysis of the constrictors, it is known as hyperemia of paralysis. When caused by irritation of the dilators, it is known as hyperemia of irritation. (Warren.) These elements, which combine to form the vaso-motor system, are so nicely adjusted that they counteract each other, and when disturbances arise in the circula- tion in one direction, a reaction in the opposite way may soon occur to restore the normal condition. Injuries of various forms which afifect the sympathetic nerves are the most common cause of the hyperemia of paralysis. Warren men- tions a case in his hospital service in which injury to the cervical sympathetic was immediately followed by changes in the pupil, and hyperidrosis of the injured half of the face and neck. Syncope following blows upon the chest and abdomen, and resulting in death or recovery, are the result, no doubt, of reflex paralysis of the heart and abdominal vessels. Blushing and the redness of the face following the use of tea, coffee, and alcoholic stimulants are considered hyperemias of dilatation. This form of hyperemia also accompanies the pain of facial neuralgia, causing flushing of the forehead and face, redness of the conjunctiva, and secretion of tears. It is also associated with hemicrania, and with certain forms of peripheral disturbances of the nervous system, the pro- duction of herpes zoster being a marked example. Recklinghausen is of the opinion that all reflex hyperemias are hyperemias of dilatation. The hyperemia observed in parts separated from the nerve-centers. 46 SURGERY OF THE FACE, MOUTH, AND JAWS. like transplantation flaps, and in other portions of the body which have been separated by division of the nerves, is caused by paralysis of the perivascular ganglia. Exudation. — Exudation is the process by which the corpuscular elements of the blood and the liquor sanguinis pass through the walls of the blood-vessels into the tissue spaces beyond. Exudation is the result of changes in the vessel-walls, which permit the passage or leak- age of the circulating fluid through their walls. Ziegler says, "It may be accepted as an established fact that in inflammation the vessel-wall is affected, but it is still questioned by some whether the affection is of the nature of a chemical alteration, or a mere widening of pre-existing intercellular spaces." Burdon Sanderson believes that "it is due to the loss of the power by the vessels of resistance to dilatation, and the loss of vital power, in consequence of which leakage takes place." Inflammation is divided into two forms, viz: acute and chronic; and these again into many varieties, according to the anatomical loca- tion of the disease, as taught by Virchow, such as catarrhal, fibrinous, parenchymatous, phlegmonous, indurative, degenerative, scrofulous, and infective. In acute inflammation the disease runs a more or less rapid course, and the symptoms are marked, while in the chronic form the symptoms are all less prominent, and any or all of the cardinal signs may be so slight as to escape notice altogether. A form between these two conditions has been denominated subacute inflammation. Catarrhal inflammation is an inflammatory condition of the mu- cous membrane in particular, wherever found in the body. Fibrinous inflammation may be regarded as the usual form found in serous membranes and the connective tissue. Fibrinous exudates, however, often form upon mucous surfaces, as in diphtheria and membranous croup. Parenchymatous inflammation is a term applied to those changes which take place in the special tissues of organs, independent of the connective-tissue frame-work, — affecting the elementary components of a tissue, — the cellular elements, — and expressed by a tendency to effusion of plastic material from the blood-vessels. Phlegvwnons inflammation is principally confined to the connective tissue in the form of abscesses. Indurative inflammation is that variety which is productive of new- tissue formations in the interior of organs. Degenerative inflammation may attack any of the tissues, and pro- duce a retrograde metamorphosis in their structure. Examples are, fatty degeneration, caseation, calcareous degeneration, etc. Scrofnlotis inflammation — the use of this term is now questioned by good authorities — is a type of inflammation occurring in cachectic INFLAMMATION. 47 individuals, whose tissues injure easily and heal slowly, and are prone to degenerative changes. Infecth'e inflammation is produced by the introduction into the blood of infective materials, usually derived from the entrance of bac- teria, or from some pre-existing inflammation. Examples are erysip- elas, pyemia, tuberculosis, syphilis. The terms idiopathic and trauniaHc, as applied to inflammation, are now considered as obsolete. General Inflannnation is the condition known as fever. Fever in- volves a rise in the body temperature, weakening and acceleration of heart-action, disturbances of the nervous system, and interruption in all of the processes of nutrition. Temperature. — The normal temperature, of the body is 98.5° Fahrenheit. When it rises above this it indicates fever; when it falls below it indicates shock or collapse. A temperature of 105° is generally considered dangerous, while 107° is usually fatal. It rarely occurs that the temperature reaches a higher degree than this, though exceptional cases are on record which reached 110° to 112°. Richet recently called the attention of the Biological Society of Paris to a remarkable case of hyperpyrexia in a woman suffering from intermittent fever. While the temperature in the morning was no higher than 102° Fahrenheit, in the evening it ascended to 113°. Upon two different occasions it rose to 114.8°. The utmost care was iised to avoid deception. Moreover, under the influence of quinin, it fell to 96.8°, and when the quinin was suspended, the temperature rose again to 118.8°. After a fresh exacerbation of longer continu- ance, the temperature fell to normal, and the patient recovered. In fevers generally the temperature is highest in the evening and lowest in the morning. In the fever accompanying di^cult dentition, it is generally the reverse of this, viz, highest in the morning and lowest in the evening. Pulse. — The normal pulse in an adult is about 75 beats per minute. In infants it ranges from 120 to 140 per minute. Very old persons have a much higher pulse-rate than people in middle life. A full, rapid, bounding pulse is indicative of high fever, and bears a relative ratio to the increase in bodily temperature. For instance, a tempera- ture of 103° would be accompanied with a pulse-rate of about 100. A soft, rapid, small, flowing pulse is indicative of great weakness, and of collapse if occurring in fevers. The pulse in severe cases of pneu- monia may run from 120 to 13b beats per minute. An irregular or intermittent pulse is indicative of functional or organic disease of the heart. 4o surgery of the face, mouth, and jaws. Symptoms of Acute Local Inflammation. Redness. — This symptom is persistent, and is due to hyperemia. By digital pressure the capillaries can be emptied, but on removing the pressure the redness immediately returns. The shade of color de- pends upon the freedom from obstruction in the vessels, and the rapid- ity of the circulation. When the color is dark or purplish it denotes stasis; rose-red streaks along the ti'ack of the lymph- vessels indicate lymphangitis; a dark red track along the course of the veins would point to phlebitis; while a copper-red color would denote syphilitic inflammation. Swelling. — This symptom is due to the engorgement of the blood- vessels of the part, to exvidation from the blood-vessels, and to prolif- eration of cells. In acute inflammations the swelling is soft; in the chronic forms it is hard. Swelling is especially marked in loose con- nective tissue. Heat. — This symptom is most marked at the center or focus of the inflamed area. It is thought to be produced by the increased rapid- ity of the circulation, and the volume of blood in the part. Hunter taught that the heat of the part was never above the heat of the internal organs. Hunter's Law reads as follows: "In inflammation the heat of the part is increased above the normal temperature of the part, but not beyond the temperature of the internal organs." Pain. — This symptom is persistent, and is increased by pressure, by motion of the part, or by general exercise. Exercise increases ar- terial tension, and thus augments the pain. The pain is most intense in dense structures, and is mainly due to mechanical pressure upon the nerve-filaments, and is sometimes reflected to regions remote from the seat of the inflammation. Examples are, knee pain in hip-joint disease, shoulder pain in hepatitis, otalgia in piflpitis. Disturbance of Function. — This symptom is marked in its action upon the secretions, which often become perverted or suppressed. The reflexes are generally exaggerated. Examples are the tenesmus of dysentery, the strangury of cystitis, the convulsions of teething. Non-sensitive parts become hypersensitive, examples being the pain of pleurisy, peritonitis, teething, or decayed dentine in vital teeth. Description of the Inflammatory Process in the Vascular Tissues. The phenomena of inflammation in the vascular tissues are best, studied in the tongue, the mesentery, or the web of the frog's foot. A good microscope is indispensable. The process may be divided and briefly described in the follow- ing order: Irritation, Hyperemia, Expansion of Blood-vessels, Re- tarded Flow of Blood, Migration of Leucocytes, Exudation of Liquor- INFLAMMATION. 49 Sanguinis, Partial Stasis, Resolution, Complete Stasis, Suppuration, Ulceration, Gangrene, Neci-osis, Somatic Death. Irritation, in some of its forms, — traumatism, heat, cold, acids, alkalies, vesicants, micro-organisms, and their products, — is always necessary to establish the phenomena of inflammation in the vas- cular tissues. Hyperemia is caused by an increased flow of blood to the part, as a result of the stimulation of irritation. Fig. 29. ^ Inflammation of the Pericementitm, showing the Leucocytes. Expansion of blood-vessels results from the increased flow or volume of blood entering them, and paralysis of their muscles. Retarded flozu of blood is caused by the continued expansion of the blood-vessels, and adhesion of the leucocytes — colorless blood-cor- puscles — to the sides of the vessels. This stage in the process consti- tutes acute congestion. Migration of leucocytes. These corpuscles escape through the walls of the vessels bv an ameboid movement, and collect in the 5° SURGERY OF THE FACE, MOUTH, AND JAWS. Fl W •T"^ ri-''^ i^^^^i^J^^-'^ .- Inflammation of the Pericementum, showing Inflammatory Exll Fig. 31. Inflammation of the Pericementum, showing Migrated Blood-Cells, and Coagulum of Plasma. (After Talbot.) X 480. INFLAMMATION Fig. 33- Inflammation ok the Pericementum, showing Stage of Degeneration and commencing Liquefaction of Tissue. (After Talbot.) X 480. 52 SURGERY OF THE FACE, MOUTH, AND JAWS. meshes of the connective tissues (Fig. 29). The red corpuscles also, in some instances, pass through the vessel-walls, but, not having the power of migration, they are consequently found in the immediate neighborhood of the blood-vessels. Exudation of liquor sanguinis causes induration and swelling, accompanied by coagulation of the fibrinous elements. The coagula- tion of this plasma incloses the migrated corpuscles, and thereby pre- vents their further movement. (Figs. 30, 31.) Partial stasis. The leucocytes adhere to the walls of the vessels. The liquor sanguinis separates and flows in a current next to the walls (plasma layer), while the red corpuscles move in a stream through the center (axial stream), occasionally stopping for a moment, and then slowly moving on again in an irregular manner. Resolution. At this stage, resolution — a return to normal func- tion — may take place under favorable conditions. The blood-current gradually resumes its natural fiow; resorption of the exudation takes place, the induration and swelling disappear, the pain ceases, and the tissues regain their normal color, or complete stasis takes place. Complete stasis is that condition in which the circulation of the blood is completely arrested in a more or less extensive portion of the inflamed tissue. (Fig. 32.) When this occurs, gangrene and necrosis are the result, and it may be followed by suppuration. Suppuration (molecular death). In suppuration the exuded blood-corpuscles or leucocytes lose their vitality. Originally they were tissue-builders, thrown out to repair damages; failing in this, degeneration and liquefaction take place (Fig. 33); they form with the exuded liquor sanguinis a thick creamy substance known as pus. Ulceration (molecular death of tissue). This process causes a break in the continuity of the tissues, and is accompanied by a dis- charge. The surfaces become vascularized, and are converted into granulations; or Gangrene (slough — death en masse of soft tissue). This condition is the result of complete stasis. The soft tissues are cut off from their nutrient supply, lose their vitality, and slough away in portions corresponding to the area thus involved. Necrosis (exfoliation- — death en masse of bony tissue). The hard tissues, when deprived of their blood-supply, also die en masse, separa- tion finally takes place between the vital and the non-vital parts, and the necrosed portion is exfoliated. Somatic death is death of the whole body. In the further study of this subject the term necrosis will be ap- plied to death en masse of bone-tissue only. Note. — The above division of the various processes in inflammation is somewhat arbitrary, but the writer believes that by this plan the student Avill better understand and retain the subject. INFLAMMATION, 53 REA^EW. CHAPTER III. What is the definition of Inflammation? Name the physical signs of inflammation. What is Irritation? What are tlie general forms of irritation? What is a Meclianical irritant? Cliemical? Septic? Nervous? Describe the general features of inflammation. How may it terminate? What two factors determine the classification of inflammation? Describe the condition known as hyperemia. What position does it occupy physiologically and pathologically? What is the definition of hyperemia? What is the definition of plethora? What is the definition of ischemia? What is the definition of anemia? Into what forms is hyperemia divided? What is the difiference between the active and passive forms? How may active hyperemia be produced? How does section of the sympathetic nerve produce hyperemia? What are the nerves called which preside over the physiologic functions of the blood-vessels? How many sets of nerves are found in these vessels? What are they called? Name the forms or varieties of active hyperemia. Describe hyperemia of paralysis. Describe hyperemia of irritation. What forms of hyperemia are considered hyperemias of dilatation? Under what conditions is paralysis of the perivascular ganglia observed? What is Exudation? What is the cause of exudation ? What are the theories in relation to the causes of the changes in the vessel- wall? Describe acute local inflammation. Describe chronic local inflammation. What is the definition of Catarrhal inflammation? What is the definition of Fibrinous inflammation? In what diseases may fibrinous exudates appear upon mucous membrane? What is the definition of Parenchymatous inflammation? How is it expressed? What is the definition of Phlegmonous inflammation? How is it expressed? What is the definition of Indurative inflammation? What is the definition of Degenerative inflammation? Name some of the forms of degeneration. What is the definition of Scrofulous inflammation? What is the definition of Infective inflammation? Name examples of this form of inflammation. What is general inflammation? What is the normal temperature of the body? 54 SURGERY OF THE FACE, MOUTH, AND JAWS. What does a sub-normal temperature indicate? What is the normal pulse-rate of an adult? What is the cause of redness in inflammation? What is the cause of swelling? What is the cause of heat? What is the cause of pain? Describe the inflammatory process in vascular tissues. What is the cause of hyperemia? What is the cause of the expansion of blood-vessels? What is the cause of the retarded flow of blood? What do you understand by the migration of the leucocytes? What do you understand bj' the exudation of liquor sanguinis? What do you understand by partial stasis? What is resolution? What is suppuration? What is ulceration? What is gangrene? What is necrosis? What is somatic death? CHAPTER IV. INFLAMMATION (Continued). SuPPUR.-\TION. Definition. — Suppuration. (Lat. siippiiratio, from suppurare, to form pus.) The formation of ptis. Suppuration is the most common or frequent termination of acute inflammation. An inflammation which terminates in this manner is termed Suppurative Inflammation. Suppuration is a process by wliich the morpliologic elements produced by the inflammation — the leucocytes and the embryonic cell formed from the fixed tissue-cells — are converted into pus-corpuscles, and the intercellular substance of the tissues is liquefied. "Suppuration takes place in the tissues by virtue of the peculiar peptonizing or digestive action which the bacteria exert upon them." (Warren.) When pus collects and forms an abscess it exerts a solvent action upon the tissues, as evidenced b}" the presence of broken-down tissue- cells and remains of tissue, mixed with pus-corpuscles. There must therefore be some chemical substance in the pus which sets up this solvent or digestive action. The direct cause of suppuration is the action of certain specific micro-organisms — the pus-microbes — upon the tissues, the leucocytes, and the embryonal cells. Pus may be produced, however, under given circumstances, with- out the presence or intervention of micro-organisms; as, for instance, by the introduction under the skin of certain chemical irritants. Heuter and his school took a radical position in reference to the power of micro-organisms to cause the production of pus, and stated that there could be no pus without bacteria. This statement met with •strong dissent on the part of many close observers, who were not ready to grant such complete control to the ubiquitous microbe. Billroth believed that bacteria were not the cause of suppuration, but only an accompaniment, and that the active cause was a chemical ferment. Pasteur and others claimed to prove this position, by pro- ducing suppuration with pus which had been subjected to a sufficient degree of heat to destroy the bacteria contained in it. It was also 55 56 SURGERY OF THE FACE, MOUTH, AND JAWS. found by experiment that certain chemical substances inserted under the skin would produce pus. Councilman first proved the fact that croton oil when injected under the skin in rabbits would produce sup- puration without the action of micro-organisms. The early experi- ments in this line were very conflicting; some observers succeeded in .producing an aseptic pus, — others a septic product, with the same chemical agent. Christmas could not produce suppuration in rabbits with turpentine or mercury, but succeeded with dogs. These conflict- ing results were due in some cases to imperfect asepsis, in others to the fact that the same chemical substance would produce suppuration in one species of animal, and not in another. Warren says, "It must be conceded that it is possible to produce suppuration without the direct intervention of bacteria, but all (authorities) are agreed that mechan- ical irritation or foreign bodies are unable to produce suppuration without the aid of bacteria." Senn believes all inflammatory wound complications, including suppuration, are caused by the introduction into the tissues of patho- genic micro-organisms, the clinical varieties being mostly determined by the intensity of the infection, the manner of localization, and the degree of resistance possessed by the tissues. The same streptococcus which produces a simple abscess is likewise the most frequent cause of progressive gangrene, and of that most grave form of suppuration known as pyemia. In suppurative inflammation two forms of leucocytes are found; one is mononucleated, the other polynucleated. (Warren.) The former is found only in limited degree in the early stages of suppura- tion in acute inflammation, but in its later stages, and in the chronic forms of inflammation, it is present in greater numbers. They are derived from the blood, and from the fixed tissue-cells. The latter are the wandering cells, described by Ziegler. They are distin- guished from the pus-cells by the larger size of the nucleus. The polynucleated cells possess two or three nuclei, or the nucleus is pe- culiarly deformicd. This change in the shape of the nucleus does not seem to be the beginning of the karyokinetic process — cell division — but rather one of degeneration preceding the final breaking down of the corpuscles. A few tissue-cells are also found mixed with the pus- corpuscles. The polynucleated cells may be considered as a type of the pus-corpuscle. In addition to the cells already mentioned, there are found larger cells, with a single large, bright, oval nucleus, known as "fibroblasts." These in the later stages of suppuration increase in numbers until they become more numerous than the pus-corpuscles, and are the active agents in the process of repair. The indirect causes of suppuration are the inflammatory phenomena INFLAMMATION. 57 of exudation, the crowding of the connective-tissue spaces with the corpuscular elements of the blood and the consequent pressure upon the capillary blood-vesels, resultnig in complete stasis and death of the tissues involved. All conditions which impair cell-nutrition favor the suppurative process. (Senn.) Death of the tissues is not alwaj's necessary to produce suppuration, but the changes which take place in the affected parts are those which are expected to follow intense irri- tation, viz: hyperemia, exudation, coagulation of fibrinous elements, and partial stasis. Suppuration produced b}' chemical pyogenic substances, like me- tallic mercury, turpentine, concentrated ammonia, and croton oil in- troduced under the skin hypodermically- — with strict antiseptic pre- cautions — produce a sterile aseptic pus, which is very different from clinical pus, while the inflammation and suppuration do not follow the progressive course of an infectious inflammation. In suppuration due to infectious inflammations, the direct cause which produces it multiplies in the tissues. Consequently it has a ten- dency to become progressive, while from the pus which is produced the pathogenic micro-organism — pus-microbe — can be cultivated, and if introduced into another organism, will produce inflammation and suppuration. (Senn.) The power of pyogenic micro-organisms to produce pus seems to lie in their ability to liquefy the fibrinous exudates; but in order to ac- complish this it is necessary that they be present in large numbers. In certain forms they exert a chemical action which results in the death of the tissues. Pus. — Pus is a thick, creamy liquid of specific gravity 1030, a prod- uct of suppuration, consisting of degenerated leucocytes, living and dead, liquor sanguinis, granular detritus from broken-down cellular structures, fat-globules, and sometimes flakes of coagulated fibrin. Micro-organisms are plentiful. Those which produce suppuration are the Staphylococcus pyogenes aureus, Staphylococcus pyogenes albus, Alicrococcus pyogenes tenuis, and the Streptococcus pyogenes. The staphylococci and the streptococci are the most common forms which produce suppuration. Varieties of Pus. — Thick, cream-like pus, without odor, coming from acute inflammation in healthy subjects, is termed good or laudable. Thin reddish pus, mixed with blood, comes from chronic ulcers and malignant disease, and is termed sanious. Thin, watery, irritating pus comes from chronic ulcers, bone- disease, etc., and is termed iciioroiis. A sanious pus, containing flakes of coagulated fibrin, coming from chronic abscesses associated with bone-disease, is termed curdy or clieesy. 58 SURGERY OF THE FACE, MOUTH, AND JAWS. Thick, ropy pus comes from syphilitic abscesses, and is termed gummy. Thin, watery pus coming from inflamed mucous surfaces, is termed muco-pus, — mucus mixed with pus. Sometimes it is very offensive, having an odor of hydrogen sulfid, when retained in cavities hke the antrum of Highmore, or the frontal sinus. The odor is the result of putrefaction. Thin, watery pus, containing considerable fibrin, coming from serous membranes like the pleura and peritoneum, is termed sero-pus. When pus is not discharged it may undergo disintegration and be absorbed, or its more liquid portions, together with the surrounding affected tissues, may undergo fatty degeneration or form a cheesy mass, which is termed caseation. Constitutional Symptoms of Acute Inflammation.— The most common constitutional symptom of acute inflammation is fever. Fever may be sthenic or asthenic in form. Sthenic fever — sthenic means strength — is characterized by full, strong, rapid pulse, flushed face, in- jected conjunctivEe, increased terhperature, — 100° to 103° F., — head- ache, lumbar pains, troubled sleep; special senses often hyperesthetic ; secretions diminished; urine dark colored, irritating, and of high spe- cific gravity; thirst, tongue coated (white or yellowish), and bowels constipated. This form of fever is characteristic of strong and robust individuals. Asthenic fever — asthenic means feeble. This form of fever is common in infants, old persons, and the very feeble. The general symptoms are the same as in the sthenic form, except that in place of overaction of the circulation there is a profound depression, followed by a typhoid condition. The pulse is feeble. The temperature fluctu- ates between 99°, 100°, to 103° F., or even as high as 105°. The mental condition is dull and torpid, at times delirious. The tongue is dry and coated, brown or black. Predisposing Causes.— Among the most prominent of the predis- posing causes of inflammation may be mentioned that of age. Nutri- tional changes in growing children readily lead to inflammatory condi- tions of the mucous membranes, and of the bones, which are not likely to occur in the adult from the same cause. In old age there is a lowering of the vital powers, resistance to the encroachment of patho- genic bacteria is less vigorous, and as a consequence many catarrhal affections are present at this period. Certain morbid conditions of the blood also predispose to inflammatory conditions, like the presence of an excess of uric acid, or of sugar. Individuals with the uric-acid diathesis are prone to rheumatic and gouty affections and to inflam- mations of the pericementum. There is a well-known tendency in individuals suffering from diabetes to the formation of carbuncles. INFLAMMATION. 59 The weakened condition of tlie system, however, may be responsible for this tendency, rather than the presence of the sugar. Infection also more readily takes place in anemic subjects from the injection of the Pyogenes aureus, as proved by Gartner, thus explaining the reason for the frequency of boils in persons of debilitated health. The excessive use of alcoholic stimulants is also a predisposing cause of inflammatory affections. Climatic influences are very potent factors in predisposing to inflammations, — in cold climates to affections of the throat and lungs, in hot climates to affections of the abdominal viscera. Symptoms and Diagnosis.- — The diagnosis of a typical case of acute inflammation occurring upon the surface of the body, with all the symptoms well marked, would be an easy matter to any one of lim- ited experience. The local symptoms of redness, heat, swelling, and pain are always present in a typical acute inflammation, while the con- stitutional symptoms of elevation of temperature, etc., are more or less marked. Its character, course, and termination will depend upon the primary cause of the affection, the condition of the patient, and the environment. According to Senn, the nature of the primary cause determines the character and course of the inflammation. The mi- crobes of suppuration, erysipelas, anthrax, glanders, tetanus, and gon- orrhea cause acute affections, while the micro-organisms of tuber- culosis, lepra, and actimomycosis cause affections which are marked by the chronicity of their course and development. Acute inflammation may become subacute, and finally chronic. Dental pulpitis and pericementitis occasionally pass through all three of these stages. In acute inflammations, where the diagnosis is clear, it only remains to decide upon the character of the infection. The fever which attends the inflammation is only a symptom, and is indicative of the introduction into the system of poisonous sub- stances resulting from the pathologic changes which have taken place in the exudates or the fixed tissue-cells, by reason of the action of specific micro-organisms. The micro-organisms which produce acute inflammation differ very greatly in their power to cause elevation of temperature from the substance which they produce in the inflamed tissues. The changes in the tissues caused by the Micrococcus pyogenes tenuis of suppuration do not produce so high a temperature as when caused by the Staphylococcus pyogenes aureus or albus, or the Streptococcus pyogenes. (Senn.) The general disturbances, such as headache, lumbar pains, loss of appetite, vomiting, constipation, feeling of lassitude, etc., which attend acute inflammations, are caused by the elevated temperature, and the presence of specific ptomaines in the blood. Just how micro-organisms cause febrile irritations, whether by the production of chemical substances which enter the blood by absorp- 6o SURGERY OF THE FACE, MOUTH, AND JAWS. tion, or by their simple presence in the tissues, cannot be definitely stated. It is a well-known fact, however, that many surgical fevers are due to the presence in the blood and tissues of a ptomaine produced by chemical changes occurring in putrefying wounds in the presence of micro-organisms. Febi^ile disturbance following injury is not always dependent upon the presence of bacteria. Genuine fever may develop in cases where perfect asepsis has been secured, and the wounds have healed by first intention. Simple fractures and other subcutaneous injuries are often followed by elevation of temperature, probably the result of shock. Warren says, "In general it may be said fever is due to the presence in the blood of a pyogenous substance of an organic nature, that may have been produced by bacteria, or have been due to the presence of bacteria, or finally, to some ferment-like substance " which has resulted from cell-disintegration;" while Senn says, "The nature of the inflammatory product always answers to the specific action of the microbe." The inflammation caused by pus-microbes results in the formation of pus, while the microbes which cause chronic inflammation as a rule only convert the pre-existing mature tissue by degenerative meta- morphosis into an embryonal form, a granulation-tissue. Those micro-organisms whose existence in the tissues is short-lived, as for instance the streptococcus of erysipelas, may give rise only to an intense hyperemia, with moderate exudation and migration of the blood-corpuscles. Genuine uncomplicated erysipelas is of such short duration that the inflammatory symptoms rapidly subside, and perfect restoration of the parts is accomplished in a few days. Prognosis.- — Resolution is the most favorable termination of in- flammation. The inflammatory process is arrested "as soon as the blood which circulates through the vessels restores their walls to a normal condition." When this condition is brought about, resolution is immediately established. The exudation ceases as soon as the vessels are restored to functional activity, and the process of resorption of the exuded plasma and leucocytes begins immediately. The simple serous exudates are those which are most readily resorbed. As soon as the normal nutrition of the part is readjusted, the constituent cells of the tissues which have been injured in the course of the inflammation take on new vigor, and soon recover their normal condition. Resolution is only possible in the milder forms of inflammation, where the migration of the leucocytes has been moderate in quantity, and where the exudates and the cellular elements have not been con- verted into pus-corpuscles. In resolution, many of the escaped leuco- cytes which have retained their vitality return through the vessel-walls into the general circulation, or through the lymphatic system. The blood-corpuscles which remain, both white and red, undergo degen- INFLAMMATION. 6l eration and liquefaction, and are removed by absorption. The coagu- lated fibrin of the exudates is transformed into a granular mass, and is then removed in like manner. The embryonal cells which have lost their vitality by reason of the inflammation are also converted into granular masses, and absorbed. The loss of tissue caused by the inflammation, if not too extensive, and if the remaining parts are healthy, will soon be replaced by the process of regeneration, accomplished through the karyokinetic func- tion of the fixed tissue-cells. The epithelial cells produce epithelium, the muscle-cells generate new muscular tissue, the periosteum forms new bone, the fibroblasts new fibrous tissue, new blood-vessels are formed by capillary ofl^shoots from existing vessels, and new nerves from nerve-cells, etc. Inflammatory exudates become a source of danger, when, by reason of their amount, they cause mechanical pressure that interferes with the performance of function in important organs, like the heart, the lungs, or the brain. (Senn.) A moderate amount of inflammatory exudation occurring in any of the meninges of the brain may cause death from compression. Effusion into the pericardium of sufficient quantity to interfere with the action of the heart would cause death by syncope. A copious efifusion into the pleural cavit}', especially if it accumulates rapidly, may so interfere with respiration as to cause death by apnoea, while a sHght edema of the glottis or diphtheritic exudation upon the vocal cords may destroy life by causing mechan- ical obstruction to the entrance of sufficient air to the lungs. The modifying influences which control the effects of inflamma- tion are the age and general condition of the individual. Infants and elderly persons have little resistive power; consequently, when at- tacked with inflammation, the disease is prone to lead to serious results. The same is true of persons debilitated from disease or ex- cesses, particularly intemperance in the use of alcoholic drinks. In tuberculosis there is always danger of extension of the disease to other organs through the specific bacilli which are carried by the circulation and lymphatic channels. "Chronic suppuration eventually causes amyloid degeneration of the important organs, and death ensues as a result." (Senn.) REVIEW. CHAPTER IV. What is the definition of Suppuration? What is Suppuration? What is its direct cause? 62 SURGERY OF THE FACE, MOUTH, AND JAWS. How do micro-organisms cause the formation of pus? What was Heuter's position in reference to the formation of pus? What was Billroth's opinion? How many forms of leucocytes are found in suppurative inflammation? Under what conditions are the mononucleated cells present? From what are they derived? How are they distinguished from the pus-cells? Describe the polynucleated cells. What is the cause of the change of the nuclei? What other kind of cells are found mixed with the pus-corpuscles? Which of these cells is a type of the pus-corpuscle? Describe the fibroblasts. What are their functions? What is the difference between the infectious inflammatory product and that produced by chemical pyogenic substances? What is pus? How many forms of pus have been mentioned? Name them. What is laudable pus? What is sanious pus? What is ichorous pus? What is curdy or cheesy pus? What is gummy pus? What is muco-pus? What is sero-pus? What becomes of pus when not discharged? What are the most common constitutional symptoms of acute inflamma- tion? What are the characteristics of sthenic fever? What are the characteristics of asthenic fever? Name the prominent predisposing causes of inflammation. How does old age predispose to inflammation? What conditions of the blood are predisposing causes? What forms of inflammation will climatic changes produce? What are the diagnostic symptoms of acute inflammation? Upon what do its character, course, and termination depend? What forms of microbes cause acute affections? What forms produce chronic affections? Of what is the fever attending inflammation indicative? How do micro-organisms cause the fever? What are the theories upon the matter? Is fever following injury ever produced without the presence of bacteria? What is the difference in the results produced by the pus-microbes of acute inflammation, and those which cause chronic inflammation? When is the inflammatory process arrested? When do the exudates cease to be formed? At what period does resorption begin? When do the injured tissue-cells begin to recover? What becomes of the vital leucocytes in the process of resolution? What becomes of those which have lost their vitality? What becomes of the fibrin and dead embryonal cells which remain? By what process is lost tissue restored? When do the inflammatory exudates become a source of danger? What modifying influences control the eft'ects of inflammation? CHAPTER V. TREATMENT OF INFLAMMATION. Senn says, inflammation is not a disease, but a symptom ; an effort ^lpon the part of the system to eliminate, or render inert or harmless the primary cause; the treatment, therefore, must be directed in each individual case to the symptoms presented. The nature and tendencies of inflammation must be thoroughly -understood in order to arrive at a rational method of treatment. Van Buren defines inflammation as "a condition located in the -apparatus of nutrition, affecting a limited area, and consisting in tem- porary perversion of nutrition from its natural and regular order." The treatment of septic inflammation, as of all other affections, comprehends the questions of prevention and cure. The subject may therefore be divided into Prophylactic treatment and Curative treatment. Prophylactic treatment is of first and greatest importance, and the old adage that "an ounce of prevention is worth a pound of cure" never had greater force, nor was ever more strongly indorsed or more firmly believed by the profession and the general public than it is to-day. The evidence of this is constantly before us in the efforts of medical and surgical science to discover means for rendering the animal economy immune to disease, and of methods of combating the spread of con- tagious and epidemic diseases. At no time in the history of the world has such great advancement been made in this direction as during the last decade. The study of the science of bacteriology has done more to awaken interest and stir enthusiasm in the subject of preventive medi- cine than all other subjects combined; in fact, it is the key to the whole situation. Prophylactic treatment in acute septic inflammation by antiseptic methods is of first importance, and is usually very satisfactory in its results. Preventive antiseptic precautions have made modern surgery what it is to-day. The surgeon or the dentist who fails to properly appreciate the value of prophylactic treatment from the standpoint of antisepsis is behind his day and generation, and cannot hope for the same degree of success in the prevention and cure of disease as those who follow the antiseptic method. The specific action of the pus- microbes is no longer doubted by. even the most skeptical. 63 64 SURGERY OF THE FACE, MOUTH, AND JAWS. Lister, the apostle of antiseptic surgery, and his early disciples, by their work and teaching, have been the means of saving thousands- upon thousands of human lives that otherwise would have been lost. The mortality of even the most desperate operations, when anti- septic methods can be used, has been so reduced that many have been encouraged to suggest and to attempt operations which at any previ- ous time would have been considered the vaporings of a diseased mind (Senn), or stigmatized as criminal. The abdominal cavity is now opened with impunity, and operations made upon the inclosed viscera that a few years ago would have been considered impossible. The chest is explored, and portions of the lung removed. The cranium is perforated, and tumors extracted from- portions of the brain, and a large percentage of the individuals op- erated upon recover, and are restored to health and usefulness. By the introduction of antisepsis the surgeon has it in his power to prevent the almost innumerable complications surrounding trau- matic injuries, and their too often fatal terminations. The preventive treatment of inflammation in relation to wounds and other avenues of infection, consists in so protecting the locality which has been deprived of its natural barrier against the entrance of pathogenic micro-organisms — the skin and mucous membrane — by first securing an aseptic condition of the parts, and maintaining this by bringing in contact with it only such things as are in themselves antiseptic, or as have been rendered aseptic by thorough sterilization. In inflammations where there is no external traumatism through which infection could have entered, it must be taken for granted that the micro-organisms have found ingress to the circulation through some slight break in the continuity of the external tissues, which has left no- mark, and has escaped the notice of the patient; or the infection may have entered through some of the various appendages of the skin or mucous membrane, and later located in some organ or part which by its abnormal condition is prepared to foster their growth, a location which has at the time a lowered vital resistive power. (Senn.) Prevent the infection of a wound by pus-forming microbes, and inflammation is prevented. Both in theory and clinical experience this axiom is eminently true. Curative Treatment. — It has already been intimated that irritation and inflammation sustain to each other the relationship of cause and efifect. It is therefore readily seen that curative treatment, to be effec- tive, must reach beyond the use of palliative measures, and destroy, eliminate, or render inert the active or exciting cause, by means, adapted to the nature, course, and progress of the inflammation and the condition of the patient. These methods may be radical or con- servative, but in either case they should be directed to the removal of TREATMENT OF INFLAMMATION. 65 the cause of irritation at the earhest practicable moment, compatible with the surrounding conditions. When the disturbing cause is purely local its removal may sometimes be easily accomplished by resorting to a surgical operation, as, for instance, the removal of a fragment of bone, splinters, bullets, or other foreign substances; the resection of diseased joints (Senn), the extraction of diseased teeth, the evacuation of pent-up secretions, releasing strangulated tissues, rendering innoc- uous infective or acrid discharges, or promptly displacing the contents of abscesses, and establishing drainage to prevent further accumu- lation. Local Treatment. — Senn says, recognizing the fact that acute in- flammation, wherever it occurs, is the result of the action of certain specific micro-organisms upon the vessel-walls and the tissues outside of them, the rational treatment would seem to be to destroy the microbes in the tissues as soon as their presence is discovered, by the saturation of the tissues with some solution having germicidal powers. Heuter advised and extensively practiced this method long before it was known that certain microbes and definite forms of inflammation had any relationship with one another. He also claimed that all inflam- mations were caused by certain noxas (harmful, hurtful, baneful sub- stances) introduced from without the body, and which he tried to combat by saturating the tissues with antiseptic solutions. His favorite remedy was a 3 to 5 per cent, solution of carbolic acid. This he introduced into the tissues by means of a Pravaz syringe, armed with a long needle having several lateral openings. In adults he often injected as much as ten grammes. In treating large, open, granulating surfaces, or tubercular foci, he used an infuser in place of the syringe. This was a graduated glass cylinder, having a rubber tube attached, and this joined to the needle; and he depended upon gravitation to diffuse the solution through the soft granular tissue. This method has never been generally practiced, for the reason that except in inflammatory conditions of very limited area, there would be too great danger of causing the death of the patient by a toxic dose of the germicidal agent. Corrosive sublimate, permanganate of potassa, nitrate of silver, iodin, and other germicidal agents, have all been used in the same way, but with no degree of satisfaction. If this method is practiced, it should be under strict antiseptic precautions, the amount of the agent introduced should never exceed the dose given internally, and the danger from a toxic dose should be remembered if the injection is repeated. Depletion. — For generations it has been the practice to deplete the system by venesection, and the internal use of emetics and cathartics, to reduce the arterial tension in inflammation, and thereby prevent, or 6 66 SURGERY OF THE FACE, MOUTH, AND JAWS. cut short, the more serious symptoms. Blood-letting is rarely ever resorted to in these days in the treatment of any form of inflammation. General depletion, if carried far enough to weaken the vital forces, diminishes the prospect of a favorable termination of the inflammation. General depletion favors stasis; local depletion often proves of great value by relieving the engorged capillary vessels, and thereby prevent- ing stasis. Leeches should never be used, as the}' often carry infection which may prove disastrous. Scarification, as generally practiced for cup- ping, is unsafe, for the reason that it is difificult to keep the instruments aseptic, and the number and depth of the incisions are not under the control of the surgeon. Local depletion is best obtained by incisions made with a scalpel, and free bleeding promoted by the use of warm water. Vomiting and diarrhea sometimes occur in the early stages of acute inflammation. This is an attempt upon the part of the system to eliminate through the gastro-intestinal mucous membrane the toxic elements which have been introduced into the circulation by the presence of the micro-organisms. This process of elimination can be promoted by administering a few doses of hydrargyri chloridum mite, followed by a saline cathartic, and will also many times control the vomiting and diarrhea more promptly than the remedies usually administered for that purpose. (Senn.) Rest. — Rest of an inflamed organ or part is one of the most valu- able adjuncts to the methods of treatment, and should approach, as nearly as possible, physiological rest. Examples, the exclusion of light from an inflamed eye; fixation of a limb with inflamed joint; pre- vention of occlusion of a tooth that has become sore from pericemen- titis; interdiction of the use of the voice in inflammatory conditions of the tonsils, pharynx, or larynx. (Senn.) Such rest often affords marked relief from the severity of the pain. The advantages of elevation of an inflamed part cannot be over- estimated, and are most manifest in inflammatory affections of the extremities. The throbbing pain is greatly aggravated when the limb is kept in a dependent position. Elevation not only relieves the pain, but greatly assists in removing the edematous condition. It is often necessary to secure complete rest of the entire body in severe cases of acute inflammation. The recumbent position is usually the best; this reHeves arterial tension, prevents unnecessary strain upon the blood- vessels, and reduces the dangers of emboHsm from the detachment of a thrombus. Persons suffering from alveolar abscesses and pulpitis find a sitting or recumbent position most comfortable ; exercise in any form increases the pain by increasing arterial tension. ■ TREATMENT OF INFLAMMATION. 6/ Cold. — Senn believes the application of cold has been resorted to indiscriminately in the treatment of inflammation. No agent is more potent for good or harm, according to the stage of the inflammatory process to which it is applied. In the early stages of inflammation, before exudation has progressed beyond its first beginnings, and the capillary vessels are dilated and only partially obstructed, it is of great advantage by producing contraction of the blood-vessels, and retard- ing the growth and multiplication of the micro-organisms. If stasis has become established, the application of cold will prove harmful, by preventing the establishment of collateral circulation, and increasing the dangers of complete stasis and death of the part. Cold is most effective in a superficial inflammation, but often proves of benefit in inflammations of the deeper structures when its use is prolonged. (Examples, the pleura, peritoneum, bones, joints, teeth, and the meninges of the brain.) The best method of applying cold is by means of the ice bag, the part being protected from the danger of freezing by being covered with a wet towel, folded several times. It is most beneficial in those cases in which congestion of the vessels is a prominent symptom, and where redness and heat are pronounced. (Warren.) Heat. — Heat is most beneficial in the later stages of inflammation, and is best applied by means of compresses wrung out of hot antiseptic solutions, covered with rubber sheeting, and reappHed as often as they become cooled. Hot fomentations favor collateral circulation, stimulate the absorption of the exudates, and relieve the pain. The surface to which the fomentations are to be applied should be thor- oughly cleansed with soap and water. Care must be exercised in the selection of the antiseptic drug; the age and condition of the patient, and the area to be covered, must be taken into consideration, to avoid producing toxic symptoms. Carbolic acid and sublimate solutions must be used with care with aged persons and little children, or with persons suffering from affections of the kidnevs. A i per cent, solution of acetate of aluminum, a satu- rated solution of boric acid, or the Thiersch solutions, are entirely safe, and quite as efficacious as the more poisonous drugs. All antiseptic solutions should be made from sterilized water. Senn thinks poultices of every name and nature should be rele- gated to the dead past, and never used by any enlightened surgeon, as they are simply hot-beds of pollution and infection. Warren says heat acts differently according to the degree used. Mild heat favors an increase of hypei-emia; greater heat causes con- striction of the blood-vessels. Constitutional Treatment. — Drugs are of little value for reducing the temperature in inflammation. The coal tar derivatives, salicylate bo SURGERY OF THE FACE, MOUTH, AND JAWS. of soda, salol, qninin, and other antip3'retics, when employed in large doses to reduce the temperature, accomplish this result at the expense of the vital forces, which are already being taxed very greatly in the effort to eliminate the poisonous elements which have been introduced by the action of the micro-organisms. Sponging the surface of the body with tepid water, or the use of warm baths, is far more effective in reducing the temperature; and besides being grateful to the patient, promotes elimination (Senn),. and the dangers from disarranging the stomach and weakening the heart by large doses of antipyretics are obviated. Cathartics are very valuable in many cases, and have probably a wider range of usefulness in inflammation than any other class of con- stitutional remedies. Their chief value lies first in removing the unwholesome ingesta and acrid fecal accumulations from the stomach and bowels. Second, by stimulating the secretions of the gastric and intestinal glands, the liver, the pancreas, etc., they assist the system to eliminate through these channels the toxic elements which have been introduced into the blood by the presence of micro-organisms. Third, by their revulsive action, which, operating upon such an extensive surface in immediate sympathy with the whole nervous system, exerts a powerful influence in withdrawing nervous action, or over-action, from the inflamed- part. Diaphoretics and diuretics are both valuable aids to other means of treatment, as they promote elimination of toxic substances. The kidneys are avenues through which are eliminated micro-organisms that reach them through the general circulation. The development of symptoms of sepsis in the course of an inflam- mation calls for the administration of diffusible stimulants, which should be used freely to ward off the dangers from approaching heart- failure. Brandy, cognac, and whiskey are the best for the purpose. Diet. — The diet should be nutritious, and well selected; meat- broths, beef-tea, and milk should be given freely from the beginning, and if the stomach will bear it, more substantial food. The days of starvation treatment have passed away, and the aim of the surgeon to- day is to sustain the vital powers of the patient, that he may make a more successful fight against disease. If the stomach will not retain food, then the strength of the individual must be sustained by nutritive rectal enemata of peptonized milk and beef-tea, in quantities of two to four ounces, alternately, every six to eight hours, as the condition of the patient suggests. Tonic doses of quinin are sometimes indicated where the inflammatory symptoms are protracted. When the appetite is defective, some of the bitter tonics will be found useful, and after the acute symptoms have subsided, the tincture of chlorid of iron will be found of great advantage. TREATMENT OF INFLAMMATION. 69 To relieve pain, chloral and phenacetin are to be preferred to opium. There is great danger in painful chronic conditions of forming the habit of taking anodynes. Caution should therefore be exercised, and it would be better to seek for the cause of the pain, and remove it by local measures, if possible, than to depend upon drugs to give relief. REVIEW. CHAPTER V. Is Inflammation a disease or a symptom? What is tlie system attempting to do by the process of inflammation? What does treatment comprehend? What is prophylactic treatment? What is preventive antiseptic treatment? What have antiseptic methods done for modern surgery? What does preventive antiseptic treatment consist of? What are the active agents that produce inflammation? How will the exclusion of pus-forming microbes prevent inflammation? What does curative treatment comprehend? What was Heuter's theory as to the cause of inflammation? How did he try to prevent it? What were the dangers of this method? What other drugs have been used for the same purpose? What is the value, if any, of general depletion in the treatment of inflamma- tion? What are the benefits of local depletion? How may this best be obtained? How does nature sometimes try to eliminate the toxic substances? How may the elimination of the toxic substances be promoted? What is the value of rest in inflammatory conditions? How does elevation of an inflamed limb relieve pain? When should cold be applied? How does it control inflammation? Where is it most beneficial? When is its application harmful? When apply heat? How is it best applied? What are its benefits? What is the eflfect of different degrees of heat? Should poultices ever be used? Why not? What value, if any, have antipyretics in inflammation? How may the temperature be reduced without the use of antipyretic drugs? What is the value of cathartics in inflammation? How do diaphoretics and diuretics prove beneficial in inflammation? 70 SURGERY OF THE FACE, MOUTH, AND JAWS. What should be the treatment when symptoms of sepsis have developed? What should be the diet in inflammation? How administered if the stomach will not retain food? What should be the treatment in cases with defective appetite? What drugs may be used to relieve pain? Should anodynes be administered in all cases? CHAPTER VI. CHRONIC INFLAMMATION, Chronic Inflammation is generally preceded by the acute form, wliich has not passed beyond the stages of partial stasis and suppura- tion, or of ulceration. Its Causes are long-continued local irritation, or functional activ- ity, constitutional- dyscrasia, or diathesis. Its most common terminations are Induration, Hypertrophy, Tumefaction, Suppuration, Ulceration, and Fatty Degeneration of the infiltrated tissues, the formation of cold abscesses from the breaking down of this degenerative tissue, and Caseation. Induration (Lat. induro, I harden). A process of hardening the tissues from coagulation of the fibrinous elements of the exudates, and new formations in the connective tissues. Hypertrophy (Lat. hyper, excess; Gr. -p^>f-'i, nourishment). Enlargement of a part due to constant irritation and congestion, re- sulting in the formation of new tissue elements of the same character. Tumefaction (Lat. tumere, to swell, facere, to make) (a tumor, a swelling). A circumscribed enlargement, caused by proliferation of cells and their organization into new tissue, often of a different character, resulting in the formation of tumors of various kinds, benign and malignant. Fatty Degeneration. A process or retrograde change, by which the albuminoid elements of the tissues and the exudates are con- verted into granular fatty matter. Caseation is a process of degeneration in pus, tubercles, etc., by which they are converted into a soft, cheese-like mass. The presence of chronic inflammation implies either a continued existence of the original cause, some abnormal condition of the general system, or both. Coucilman thinks "the condition of the individual has often much to do with the chronicity of inflammation." A feeble condition of the circulation results in a tardy and incomplete resorp- tion of the exudates. The local manifestations of chronic inflammation differ from the acute form only in the degree of severity. The cardinal symptoms are all less marked, or may be so slight as to escape notice altogether. 72 SURGERY OF THE FACE, MOUTH, AND JAWS. The vascular changes in the tissues which have been already de- scribed come on more slowly, and never assume the degree of severity which is characteristic of the acute form, and for this reason the migra- tion of the leucocytes takes place much less rapidly, and in some instances does not occur at all. According to Senn, the inflammatory product is composed largely of effused plastic lymph, which undergoes partial organization and causes induration, and of embryonal cells derived from the fixed tissue- cell. Sometimes the inflammatory product is largely or entirely com- posed of these embryonal cells. This is explained by the action of the noxious elements which cause chronic inflammation exerting their baneful effects more directly upon the tissue-cells than upon the capil- lary blood-vessels. The effect upon the tissues is to convert the mature tissue-cells into an embryonal form, and to increase their proliferation, thus form- ing graniilation-tissuc which remains in this condition so long as the primary cause of the inflammation retains its pathogenic qualities, or until degenerative changes take place in the new cells. Warren says, "If the exudation goes on to such an extent that the part is completely infiltrated with leucocytes, the structure of the tissue will be seriously impaired and the fibers and cells of the part disappear. The fixed cells undergo proliferation and become indistinguishable from the migratory cells, the intercellular substance is gradually changed into a more or less homogeneous granular material in which the new cells are imbedded, which constitutes granulation-tissue." The degenera- tive change which most frequently takes place in this temporary tissue is fatty degeneration, and this may break down and liquefy, forming cold abscesses. If degenerative changes do not take place in the embryonal cells, and the primary cause ceases to exist, the new cells are either resorbed or converted into mature tissue, and the inflammation results in a hyperplasia of tissue. Chronic inflammation includes all that class of affections known as "inflammatory swellings," or granidoinata. All of the inflammatory swellings are composed of granulation-tissue irrespective of the nature of the primary cause. The granulomata have been classed by some eminent pathologists with the neoplasms or tumors, because their development is usually attended with none of the characteristic symp- toms of inflammation; and on account of their tendency to spread to adjacent tissues and involve remote parts by dissemination through the lymphatic system, they have a close resemblance to the malignant growths. The granulomata are true inflammatory products. Under the microscope they exhibit all the characteristic appear- CHRONIC INl'LAMMATION. 73 anccs of inflammation, and histologically are composed of embryonal cells, representing the type of tissue from which they had their origin. Tuberculosis, syphilis, and actinomycosis are examples of inflam- matory swellings or granulomata. Treatment. — Local treatment in chronic inflammation would be the same as that followed in the acute form of the affection, as far as the removal of the cause is concerned, the same means being used in both. Another method of treatment sometimes resorted to by surgeons is to convert a chronic inflammation into the acute form of the affection, as this is nature's way of establishing a cure. This may be accom- plished b}' various drugs, such as iodin, nitrate of silver, etc., or the actual cautery or the electro-thermal cautery. Stimulating applications like the ammonia liniment, tincture of iodin, etc., are useful as aids in promoting resorption. Counter-irri- tants are sometimes serviceable, but if applied indiscriminately are likely to do more harm than good. Massage is an exceedingly important and efficient means of treat- ment in chronic inflammatory affections, when scientifically practiced. Its value lies in the fact that it stimulates the vessels to increased action, assists in restoring a normal circulation through the injured capillaries, and greatly promotes the process of resorption. The application of hot and cold douches, rest, active or passive movements, etc., adapted to the individual case, will often prove of great benefit and materially hasten a cure. Constitutional treatment is of the utmost importance in many forms of chronic inflammation, from the fact that there is associated with the local condition a constitutional or systemic dyscrasia, often more alarming than the local manifestation. Fortunately, however, many of these cases, though they differ widely as to the pathologic characters of the systemic dyscrasia, may be classified clinically as examples of enfeebled constitutions, and as ■demanding nutritious food, tonics, and perhaps stimulants. (Ham- ilton.) Such cases are greatly benefited by improved hygienic sur- roundings, fresh air, sunlight, exercise, nutritious food, tonics, etc., a sea voyage, a trip to the mountains or the seashore. In tubercular inflammation cod-liver oil and iodin are demanded. In syphilitic inflammations, represented by the gummata, vigorous antisyphilitic treatment soon causes the local lesion to disappear, and greatly improves the general health. The other specific causes of general enfeebled health are diseases of the digestive organs, the liver and the kidneys, the rheumatic and gouty diathesis, septicemia, pyemia, or other blood-poisoning. These conditions must be combated and the general health improved before a subsidence of the inflammatory symptoms can be reasonably 74 SURGERY OF THE FACE, MOUTH, AND JAWS. expected. Gouty and rheumatic conditions may be relieved by a care- fully-selected diet and the administration of the salicylic compounds;; while inflammations depending upon blood-poisoning will demand other "special agents adapted to the elimination of specific micro- organisms and their products, such as the compounds of mercury and' iodin. REVIEW. CHAPTER VI. What are the causes of chronic inflammation? What are its most common terminations? What is induration? What is hypertrophy? What is tumefaction? What is fatty degeneration? What is caseation? What does the presence of chronic inflammation implj'? How does the condition of the individual favor chronic inflammation? How do the local manifestations of chronic inflammation differ from the- acute forms? How do the vascular changes differ? Of what is the inflammatory product largely composed? What causes the induration? From what are the embryonal cells derived? What part do they form of the exudate? What is the effect of the poisonous elements upon the mature tissue? How is the granulation-tissue formed? What degenerative changes may take place? What becomes of the embryonal cells after the primary cause of the inflam- mation has been removed? What class of afifections does chronic inflammation include? How have the granulomata been classed? Why should they not be classed as neoplasms? By what appearances are they classed with the inflammatory swellings? What is tlie local treatment of chronic inflammation? What method is sometimes practiced to change the character of the inflam- mation? What is the value of local stimulation? Are counter-irritants serviceable? — to what extent? How does massage benefit? What is the condition of the general system in chronic inflammation? How should such cases be treated constitutionally? What remedies are demanded in tubercular inflammation? How should syphilitic inflammation be treated? What other specific causes engender enfeebled health? How may gouty and rheumatic conditions be relieved? How may noxious elements in blood-poisoning be eliminated? CHAPTER VII. ABSCESS. Definition. — Abscess (Lat. absccdcre, to depart). An abscess is an accumulation of pus in the tissues surrounded by a wall of lymph (formerly termed the pyogenic membrane, from the erroneous notion that it secreted pus). An abscess may be termed a hollow ulcer. When a collection of pus occurs in such locations as the pleura, pericardium, Fallopian tubes, pelves of the kidneys, peritoneum, etc., the prefix pyo, added to the anatomical name of the locality, indicates the presence of pus; thus: Pyo-thorax, pyo-pericardium, pyo-salpinx, pyo-nephrosis, pyo-peritonitis, pyo-ulitis. Causes. — Suppurative inflammation always precedes the formation of an abscess. Excessive and continued irritation causes so copious an exudation that the lymph-channels are blocked, complete blood-stasis occurs, and coagulation follows. The leucocytes lose their vitality, pressure upon the connective-tissue cells involved in the inflamed area produces a like result in them, and by the action of the micro-organ- isms which have gained an entrance through the circulation or by other avenues, the tissues and exudates are converted into pus. When the bacteria accumulate in a mass, as they frequently do, at some particular point in the system, the concentrated action of the bacteria, or of the chemical product, causes coagulation of the serum and of the contiguous tissue,— "coagulation necrosis," — thus forming- a nidus or central point for the development of suppuration, and the formation of an abscess. Around this central point, composed of dead tissue, and containing a nest of micro-organisms, the leucocytes accumulate in great numbers, completely inclosing it by forming a kind of wall. The central mass of dead tissue, and the immediately surrounding intercellular substance, soon begin to liquefy. This liber- ates the leucocytes, which were entangled in the meshes of the inter- cellular substance, and they become mixed with the pus. This pro- cess continues, and the fluid contents of the abscess gradually increase in amount ; tension of the tissues results, and they eventually give way at the location offering the least resistance. This is termed "pointing," and through this opening the contents are discharged. Active cell 75 76 SURGERY OF THE FACE, MOUTFI, AND JAWS. proliferation in the fixed tissue-cells is going on at the same time in the outer portion of the wall of leucocytes. Lining the abscess cavit}- is a tissue known as "granulation-tissue," which by its growth repairs the damage caused by the destruction of tissue. This tissue is com- posed chiefly of small, round cells, with scanty intercellular substance, but very rich in capillary blood-vessels. Classification. — Abscesses may be classed as superficial and deep- jcatcdj diffuse (phlegmonous) and circumscribed, acute and chronic. Superficial or subcutaneous abscesses have a tendency to spread laterally. This is explained by the fact that the pus moves in the direc- tion of the least resistance. The loose subcutaneous connective tissue favors this route of extension, and offers but little resistance to the pressure caused by the accumulated pus. Deep-seated or sub-fascial abscesses burrow along the sheaths of muscles and blood-vessels in the connective tissue, and may even dis- sect the periosteum from the bone. Such cases are not infrequently met with in connection with abscesses of the neck resulting from abscessed teeth, or abscesses resulting from the irritation of unerupted lower third molars, and in compound fractures of the lower jaw fol- lowed by septic inflammation. Inflammation of the lymphatic glands situated in the upper triangle of the neck, or in the submaxillary tri- angle, frequently results in the formation of deep-seated abscesses, which burrow downward to the anterior mediastinum. This is caused by their inability to penetrate the deeper layer of the cervical fascia, the action of the law of gravitation which carries the pus downward, and the slight resistance offered by the intermuscular connective tissue. The retropharyngeal abscess is an example of a still deeper variety. This abscess is situated in the space between the oesophagus and the spine. The anatomical relations of the part prevent the pointing of the abscess at its primary seat; the oesophagus being in front, the spine behind, and the sheaths of the blood-vessels — which are quite unyield- ing in this location — on either side, while the space between is com- posed of loose connective tissue, which favors its downward course into the posterior mediastinum. In the early stages the symptoms are often not well marked. Such abscesses occasionally point at or near the jaw, but more often they follow the downward course already indi- cated. Retropharyngeal abscesses usually originate in a tubercular nodule located in the body of a cervical vertebra. Diffuse (spreading, — phlegmonous) abscess is a term applied to that form of abscess which spreads in various directions. Its location may be in the subcutaneous connective tissue, submucous tissue, inter- muscular connective tissue, or subperiosteal tissue. This form of abscess is caused by the infection of the tissues with the pus-producing streptococci, and the favorite routes through which it spreads are the ABSCESS. JJ connective tissues and the lymphatic glands. The term diffuse [•iintlcnt infiltration is sometimes applied to this form of abscess. In this type of the affection, all the symptoms of acute inflammation are present, and the extent of the involved tissue is often considerable. The swell- ing is usually great, and the surface of the distended integument may develop vesicles filled with serum. The constitutional symptoms are also well marked, the disturbance sometimes being profound. Famil- iar examples of this form of abscess are those associated with infectious inflammations of compound fractures, and other injuries. Phleg- monous erysipelas is a more severe form of this same type of inflamma- tion. The diffuse suppurative inflammation following the infection of dissecting wounds, "malignant edema," is the gravest form of the affec- tion. In this type of inflammation the process is very rapid and intense, the tissues are quickly overwhelmed by the action of the poison, resulting in extensive death of the tissues, and sometimes causing a fatal termination from acute septicemia before the suppu- rative process has become established. Circumscribed abscess is a term used to designate a form of abscess possessing defined limits. This is the most common form of abscess. It is the result of a suppurative inflammation, having limited or circum- scribed boundaries, and is an opposite condition to diffuse abscess or purulent infiltration. A furuncle (boil) or an alveolar abscess are common examples of this form of the affection. Circumscribed abscess may be located in any part of the body, in any vascular tissue. It is also occasionally found in the ivory of the elephant's tusk (a non-vascular tissue) at considerable distances from the pulp, and completely encapsuled. .Such conditions must have been the result of injury to the pulp of the tusk, as suppuration in a tissue without a vas- cular system is an impossibility. Professor Busch, of Berlin, exhibited several specimens of this character at the Ninth International Medical Congress, held at Washington, D. C, in 1887. He beheved them to be the resuh of injury to the pulp, causing suppurative inflammation. The tusk of the elephant grows continually during the life of the ani- mal; the odontoblasts must, therefore, be in a state of constant func- tional activity, which would explain the fact of the abscess cavities being removed to such distances from the pulp by growth of the tissue from its base. This would also explain the encapsulation of the pus by the formation of secondary dentine. In all of these specimens the pus was dried up, leaving the cavity empty. The micro-organisms most commonly found in acute abscesses are the staphylococci and the streptococci. The pus found in cold abscesses often contains but few micro-organisms, and sometimes it seems to be entirely free from them. The staphylococcus is more frequently found in circunoscribed 7° SURGERY OF THE FACE, MOUTH, AND JAWS. abscesses, while the streptococcus is more prone to give rise to diffuse purulent infiltration. (Senn.) The size of the abscess will be determined by the character of the primary cause of the inflammation, its location, the age, habit of life, and diathesis of the patient, and the condition of the tissues involved. Tissues which have been debilitated by a previous inilammation, a contusion or other injury, have not the same resistive powers as healthy tissues; consequently abscesses developing in these locations reach much greater dimensions. In individuals whose vital powers have been impaired by old age, improper or insufficient food, the drink habit, mental anxiety, or some previous acute or chronic ailment, acute suppurative inflammation has a greater tendency to rapid extension than in healthy persons. Acute Abscesses. — An acute abscess or hot abscess is the usual termination of an acute circumscribed, suppurative inflammation. Its most common location is the connective tissue. Its direct cause is infection from micro-organisms, — the staphylococcus most frequently. Its contents are the characteristic yellowish, cream-like pus and shreds of devitalized connective tissue. It runs a rapid course, reaching" its maximum size in a few days after the first signs of inflammation have appeared. The opening of the pulp-chamber of a devitalized tooth, which before had been impervious, or the plugging with a dressing or a filling of an open pulp-canal, either with or without a sinus, through the alve- olus, is sometimes immediately followed by an acute phlegmonous inflammation, when strict antiseptic precautions have not been taken, or the caliber of the canals is so small as to preclude the possibility of rendering them aseptic. In such cases the inflammation rapidly extends to the surrounding connective tissue, producing septic cellu- litis, which follows along the intermuscular septa, fascia, etc., with great swelling and tension, and accompanied with lymphangitis. The constitutional symptoms are marked by high temperature, rigors, fol- lowed by profuse sweating, and other symptoms of grave disturbance. Occasionally it may result in gangrene, and finally death of the patient. One case of this character, associated with a lower third molar as the starting point of the inflammation, came under the observation of the writer at Mercy Hospital. Symptoms. — The local diagnostic signs or symptoms of acute abscess are, throbbing pain, increasing swelHng, surface reddened, and sometimes glazed; fluctuation discovered by palpation, percussion, and pressure; tendency to point. Pointing always occurs at the loca- tion of least resistance. Constitutional symptoms are rigors, fever, loss of appetite, general malaise, and thirst. Under ordinary circum- stances the diagnosis is simple, but occasionally it becomes more diffi- ACSCESS. 79 •cult on account of the modification of the symptoms, depending upon the primary cause of the suppurative inflammation, its location, and the character of the tissues involved. Grave blunders have sometimes occurred through relying too implicitly upon one, or even all, of the symptoms, vi^hen so modified. Aneurisms have been opened under the belief that they were abscesses. An angeioma may likewise be mistaken for an abscess. To avoid such accidents, the exploring needle, or exploring syringe, should always be used in doubtful cases. Too much care cannot be exercised, as some of the ablest and most careful surgeons have had these unfor- tunate experiences. Treatment. — "Ubi pus ibi evaciio." This rule is as wise to-day in the treatment of acute abscesses as it was centuries ago. Many sur- geons have abandoned expectant treatment, and now cut down upon the abscess as soon as a sufficient quantity of pus has been formed to make the diagnosis clear. (Senn.) Much suffering may be saved by the adoption of this method of treatment. In opening an abscess, the surface should always be first carefully cleansed, and other antiseptic precautions preserved, while the incision should be made at the most dependent part. In large abscesses, sev- eral small incisions, not over an inch in length, are better than one large one which lays open the entire cavity. Evacvtate the pus and irrigate the cavity with some bland antiseptic solution, — boric acid or Thiersch solution, — until the fluid runs clear, after which insert one or more drainage-tubes, as the case may require, and dress with antiseptic gauze, oakum, or other sterilized material. Antiseptic solutions.- — The trend of treatment by antiseptic solu- tions to-day is toward those which do not coagulate the proteid ele- ments. Corrosive sublimate has been considered as the most valuable of all the drugs for use in antiseptic surgery, and this idea has been most thoroughly instilled into the minds of medical and dental stu- dents. Koch, through whose experiments and statements the mer- curic chlorid solutions received such a boom, exaggerated its antiseptic value, or overlooked the differences which must always be reckoned upon between laboratory experiment and clinical experience. The coagulating property of the mercuric chlorid is undoubtedly a great hindrance to its practical usefulness, as it reduces its powers of penetration. Sir Joseph Lister has recently announced that he has entirely abandoned the use of the sublimate solution in favor of carbolic acid. He says, "A 5 per cent, solution of carbolic acid is more trustworthy as a germicide, for surgical purposes, than corrosive sublimate, and in other respects greatly to be preferred. "A great advantage of phenol seems to be that it has a powerful OO SURGERY OF THE FACE, MOUTH, AND JAWS. affinity for the epidermis, penetrating deeply into its substances, and. mixing with fatty materials in any proportion." Some of our best surgeons have to-day discarded all antiseptic- drugs, relying upon soap and sterilized water for cleansing the sur- faces, sterilized water alone for all other purposes, and simple steriHzed materials for dressings, and they claim as good results as when they depended upon antiseptic drugs. This emphasizes the fact that it is better to prevent the ingress of pathogenic micro-organisms than to attempt to destroy them after they have gained entrance to the tissues; also that surgical cleanliness is more valuable than drugs. In wounds, and in suppurative conditions of the oral cavity, anti- septic solutions are indispensable, but solutions of mercuric chlorid and carbolic acid have no advantages over the boric acid or the Thiersch solutions, while they have the disadvantage of being irritating to the mucous membrane if used of sufficient strength to be of real value as- germicides, as well as poisonous if by accident they enter the stomach. Methods of Opening Abscesses. — Abscesses as large as a hen's egg will not generally require more than one incision. In deep-seated abscesses, it is best to incise the skin and fascia, and then with a pair of sharp-pointed hemostatic forceps tunnel the tissue until the abscess is reached; then unlock the handles of the for- ceps and separate the blades sufficiently, so that on withdrawing the forceps an opening will be made large enough to admit a drainage-tube of the proper diameter. This method is especially valuable when the abscess is located in the neighborhood of important vessels and nerves, as it thereby greatly reduces the dangers of wounding them. It is the- safest method to follow in opening large, deep-seated abscesses in the neck. In the treatment of alveolar abscesses, the disease may be cut shorf. by trephining the external alveolar plate at the point of suppuration. To prevent a recurrence, the pulp-canals must be rendered aseptic, and maintained in that condition by proper dressings, temporary or permanent fillings. Dressings. — In the application of dressings to external abscesses,. care should be taken to insure equable compression, that the surfaces of the abscess cavity may be kept in apposition. Where drainage-tubes are used, these should be shortened from time to time, and entirely removed as soon as suppuration has ceased. Healing of Abscesses.— Abscess cavities, when aseptic, heal by granulation. Absolute rest of the part is a valuable adjunct to the treatment. Patients with large abscesses should be kept in bed. The principal causes of retarded healing are imperfect drainage, non-apposition of granulation surfaces, hemorrhage, rupture of the- limiting' walls, permitting" infiltration of pus into the surrounding con- nective tissues, indolent granulations, or constitutional dyscrasia. In the latter conditions, general tonic treatment is indicated. Chronic Abscess. — Chronic abscess differs from the acute form in that its course is slow, the signs or symptoms are greatly modified, or wanting altogether. It is usually painless, not tender to the touch, and causes little or no febrile disturbances. The tendency to point is less marked, and pus accumulates often to an extraordinary amount before the skin shows any sign of yielding. Generally the pus-cor- puscles are considerably disintegrated, the abscess walls are greatly thickened, and show signs of organization into connective tissue, and with very little tendency toward healthy granulation. The condition is one of passive congestion, with slight develop- ment of inflammatory heat; hence the terms, congestive abscess and cold abscess. Causes. — Chronic abscess may generally be traced to some specific chronic inflammation, most often of a tubercular nature. The forms most frequently coming under the observation of the oral surgeon are alveolar abscesses, caused by specific infection from devitalized teeth, abscesses of the face and neck from chronic inflammation of unerupted third molars, or portions of necrosed bone, tubercular or syphilitic inflammation of the jaws, tubercular inflammation of the cervical glands, and retropharyngeal abscess. Abscesses in connection with unerupted third molars and the cervical glands often burrow down- ward, following the septa between the muscles, and point as low down, sometimes, as the clavicle and mammas. When large chronic abscesses rupture spontaneously, or are opened with the bistoury, profuse suppuration and hectic fever quickly develop, frequently preceded b)^ rigors, and followed by profuse sweating. Occasionally, under such conditions, emaciation is rapid and continuous, and the patient dies from septic infection. Symptoms. — The diagnosis of chronic abscess depends more upon the careful consideration of the symptoms of the local lesion from which it started than upon the location, size, and special features of the swelling. (Senn.) Tubercular affections are usually accompanied by such well-marked symptoms at the stage when abscesses form, that there is very little difficulty in locating the primary lesion. The same is true of chronic abscesses originating from unerupted third molars. An exploratory puncture, and a microscopic examination of the contents of a chronic abscess, will many times be necessary to a posi- tive diagnosis as to its character. In tuberculosis, the product of tissue proliferation coagulates, dies, and disintegrates into a granular mass, which when mixed with serum in sufficient quantity forms an emulsion that to the unaided eye closely 82 SURGERY OF THE FACE, MOUTH, AND JAWS. resembles pus, but which the microscope proves to contain none of the histologic elements found in pus. Secondary infection of tubercular, actinomycotic, or syphilitic les- ions may take place from the localization of the pus-microbe, and true chronic abscess result, or occasionally be followed by an acute phleg- monous inflammation. Generally, however, no acute symptoms develop. Treatment.- — Surgical interference in the treatment of chronic abscess is never so urgent as in the acute form, on account of its slower development and slight constitutional disturbance. The abscesses appear months, and sometimes years, after the first development of the primary cause. It has already been stated that acute abscess should never be opened without antiseptic precautions. This principle needs to be doubly emphasized in the treatment of chronic abscess, especially that form known as cold abscess. The antiseptic precautions in the latter form should be of the most rigid and elaborate character, in order to guard against the dangers from septic infection, and a possible fatal result. To avoid these dangers, the German surgeons advocate evacuation by aspiration, and iodoform injections, in preference to incision and drainage. Aspiration in tubercular abscess is generally unsatisfactory, for the reason that the needle or trocar soon becomes clogged by the shreds of dead tissue, and renders complete evacuation impossible. In those cases where the seat of the primary lesion can be reached by an incision of the abscess, this is the proper method, as it gives opportunity to remove the infected tissue or the cause of infection. The abscess cavity should then be thoroughly scraped out (curetted), and all infected tissue removed, cleansed with antiseptic solutions, dried, covered with iodoform or boric acid, and treated as a recent wound, by suturing, drainage, and antiseptic dressing. In those cases caused by devitalized teeth, unerupted teeth, or necrosed bone, rational treatment would demand the immediate removal of the cause of irritation as soon as the diagnosis could be made clear. Constitutional treatment comprehends a generous diet, stimulants, and tonics, — iron, cod-liver oil, etc. ABSCESS. 83 REVIEW. CHAPTER VII. What is an abscess? What does the prefix pyo denote when coupled with pleura, etc.? What form of inflammation always precedes the formation of an abscess? How is an abscess formed? What term is applied to the natural opening of an abscess? What process is going on at the same time in the outer portion of the wall of leucocytes? What lines the abscess cavity, and what is the function of this tissue? Of what is this tissue composed? How are abscesses classed? What is the tendency of superficial abscess? In what kind of tissue is it usually found? How can the tendency to spread be explained? What is the tendency of deep-seated abscess? What are some of the causes associated with the mouth that are productive of this form of abscess? Under what other conditions are these abscesses found in the neck? How far down do they sometimes burrow? What causes operate to produce this condition? What form of abscess represents a deeper location? Where is retropharyngeal abscess located? What are the anatomical relations of the parts? What is the character of the early symptoms? In what location do these abscesses point? What is the cause of retropharyngeal abscess? Name the terms applied to diffuse abscess. What is its tendency? In what tissues is it usually located? What is the cause of this form of abscess? By what routes does it usually spread? What is the character of the local and constitutional symptoms? What are the affections in which it is most frequently seen ? Give an example of a more severe form of this type of inflammation. What is the gravest form of this type of inflammation? From what is it caused? What is the character of the symptoms? What are its tendencies? What is a circumscribed abscess? Give an example. Where may this form of abscess be located? Is it ever found in non-vascular tissues? What is the explanation of its presence in the elephant's tusk? What species of micro-organisms is most frequently found in circumscribed abscesses? Which species is most prone to give rise to diffuse purulent infiltration? What conditions determine the size of the abscess? Describe an acute abscess. What is its most common location? 84 SURGERY OF THE FACE, MOUTH, AND JAWS. What is the character of its contents? Wliat are the diagnostic signs of acute abscess? What precautions should be talcen in diagnosing doubtful cases? What general principle should be followed in the treatment of acute abscess? What precautions should be observed in opening acute abscess? Where should the incision be made in opening the abscess, and why? What treatment should follow the evacuation of the pus? What antiseptic solutions are considered best? What are the objections to corrosive sublimate? What advantage has phenol over sublimate solutions? Are antiseptic drugs used by all surgeons? What does the discarding of antiseptics imply? What class of antiseptics are most desirable to use in the mouth? Are antiseptics necessary in wounds of the mouth, and why? What operation will shorten the duration of an alveolar abscess? How prevent a recurrence of the abscess? How does a chronic abscess differ from the acute form? What are the causes of chronic abscesses? What forms are most commonly found in the region of the face and mouth? What are the methods of diagnosis? How does the surgical treatment differ from that followed in acute abscesses? What should be the constitutional treatment? CHAPTER VIII. ULCERATION. Definition.- — Ulceration. (Lat. ulcus, a sore.) An ulcer is an open sore; a destructive loss or solution of contin- uity upon any of the free surfaces of the body, which will not permit of repair by primary union ; a molecular death of tissue. It owes its existence to an excess in action of the retrograde changes over those of repair. The difference between an open granulating wound and an ulcer is that the wound shows a tendency to heal, while the ulcer shows no such tendency, but on the contrary is often inclined to spread. The explanation is that in the granulating wound the primary cause has ceased to exist, while in the ulcer it is still persistent, or infection has been introduced. An open granulating wound may become an ulcer ar any time if the granulation -tissue takes on a retrogressive change. This change may be induced by infection with the pus-microbe, from mechanical or chemical irritation, from dressings, the presence of a foreign substance, or the chemical action of drugs applied to the wound. Ulceration and gangrene are closely allied to each other, the dif- ference being that ulceration is the death of cells, the fixed tissue-cells and the embryonic or new-formed cells ("cell necrosis"), while gan- grene is death en masse of tissue (formed tissue). All wounds, of whatever nature, which do not heal by primary union or "first intention," heal by the process of granulation. (Fig. 34.) A granulation is composed of a capillary loop about which are clustered a number of living leucocytes, held together by a delicate intercellular material. Healthy granulations are cherry red in color, non-sensitive, elastic, and discharge a laudable pus. An ulcer is quite indefinite as to its size, and variable as to its shape. It is usually round, but ma}' be reniform, irregular, or serpigi- nous. It may be deep or shallow, with abrupt or with sloping sides, and a smooth or an irregular base. Its edges may be sharp or round, everted or undermined. The surface is covered with coarse granula- tions, dark red in color, which bleed readily. The surface may be 86 SURGERY OF THE FACE, MOUTH, AND JAWS. clean or sloughy, and covered with pus or serum. On healing, it always leaves a scar. A vertical section of an ulcer examined microscopically reveals the following conditions: First, a layer of pus upon the surface; pro- jecting into the pus fine capillary loops, surrounded by living leuco- cytes, constituting granulations. Beneath this is a zone of thickened inflammatory tissue, consisting mainly of fine fibrous tissue, and underneath this again a zone of hyperemia, where the capillaries are very numerous, and the leucocytes are in excess. Beyond this are healthy tissues. Ftg. 34. Granulation-Tissue— Blood-Vessfls and Matrix. ■ 75. The ulcerative process is so intimately associated with inflamma- tion, suppuration, gangrene, phagedena, granulation, and cicatriza- tion, that it is impossible to detach it from any one of these and call it a separate and definite process. Causes. ^ — The catises of ulceration may be divided into constitu- tional and local, predisposing and exciting. The predisposing causes are those which operate through the general system, and comprehend changes in nutrition, in the quantity and quality of the blood, peculiar dyscrasise and diatheses, and the freedom and rapidity of the circulation. Familiar examples are seen in persons who are badly nourished or debilitated by disease, such as tubercular affections, intestinal disorders accompanied by exhausting ULCERATION. 8/ discharges, typhoid fever, diabetes, scurvy, syphiHs, mercurial poison- ing, and dropsy. Age. — The influence of age is often stated to be an important factor in the etiology of ulcers. Old age is without doubt a period marked by many retrogressive tissue-changes, and by diminished physical power and vital resistance, which predispose to and favor the ulcerative process, and yet statistics show only a very slight increase in the percentage of this affection among the aged. Sex. — Sex seems to be a potent factor in the determination of ulcers. Statistics show that ulcers are three times as prevalent among men as among women. This may be explained, however, by the fact that men are subject to much greater exposure to injuries, and are more liable to contract syphilis or the habit of intemperance. Occupation. — Occupation owes its influence to the degree of exposure to traumatism. The greatest number of individuals suffer- ing from ulcers come from the laboring classes. Among the most prominent predisposing causes of ulcers are neglect and filth. It therefore happens that a greater number of cases of ulceration are found among that class of individuals whose habits of personal cleanli- ness are not good, whose means or lack of means prevents the proper care of the lesion in its earlier stages when it might be easily cured. Trauinatism. — Traumatisms are the most frequent cause of ulcers of the skin and mucous membrane, at least of the acute variety. The degree of injury necessary to produce an ulcer will depend upon the individual peculiarities of the constitution. The young and the robust adult will resist an injury which in the aged might result in extensive death of tissue. In the feeble and those afflicted with some constitu- tional dyscrasia like tuberculosis, syphilis, gout, diabetes, etc., slight injury often causes death of tissue, with sloughing and the formation of troublesome ulcers. Classification. — Ulcers are usually classed according to their mode of origin, and are divided into two groups, the non-infections and the infectious. Among the non-infectious ulcers may be classed all those which are caused by friction, pressure, and other mechanical injuries, and those which arise from chemical irritation or from trophic changes due to enervation, general faulty nutrition, and impeded local circula- tion. The great majority of ulcers are the result of the action of vari- ous forms of infectious micro-organisms, such as the pyogenic bacteria, those of tuberculosis, syphilis, leprosy, glanders, and perhaps cancer. Ulcers which are not caused primarily by the action of path- ogenic bacteria usually become infected as soon as an open wound is formed, by the bacteria invading the exposed surfaces, and establish- ing the inflammatory process. His SURGERY OF THE FACE, MOUTH, AND JAWS. Ulcers are also classified according to certain changes, compli- cations or modifications which may occur in them. These changes, etc., are indicated in the terms applied in the classification, such as inflamed, crcthistic (irritable), fungous, hemorrhagic, torpid, callous, cor- roding, perforating, phagedenic, and malignant ulcers. An inflamed ulcer is one having its base and surrounding parts in a state of more or less acute inflammation; the surface is very red; it bleeds easily, and the formation of pus is plentiful. The edges of the ulcer are swollen and raised, the surrounding skin is exceedingly ten- ' der, dense and shining. Ulcers of this character are often verj' painful. The causes which produce these conditions are neglect, contact with acrid secretions, or the application of substances of an irritating char- acter. The erethistic or irritable ulcer possesses extreme sensitiveness which is exceedingly difficult to relieve. It is most often located in parts which are highly sensitive, like the anus. These ulcers have the appearance of granulating surfaces in which the active process of repair has been arrested. The edges are abrupt, and show no evidence of a tendenc}^ to cicatrize; thej' are exceedingly tender, the slightest touch causing intense pain. The cause of the exceeding sensitiveness has been thought to be the thinness of the granulation- tissue. It is more often associated with nutritional changes due to anemia resulting from the loss of blood or from severe disease. Upon a re-establishment of the normal conditions of nutrition, the exalted sensibility passes away. The fungous ulcer is the result of an exuberant growth of granu- lation-tissue. It is caused by an over-supply of blood to the part, which results in the rapid growth of capillary loops from the pre- existing blood-vessels, while the epithelial cells present a sluggish kinetic function, which retards the process of repair. Fungous gran- ulations in a wound, or an ulcerating surface, are popularly known as "proud flesh." Such a condition is an obstacle to the process of repair. Fungous granulations are frequently seen protruding from the external opening of fistulous tracts, especially those leading to tubercular abscesses, necrosed bone, or other foreign body. Occa- sionally the granulations will be so large as to protrude beyond the surrounding surface of the skin, sometimes presenting a mushroom appearance, with a narrow pedicle. This condition is due to the growth of the epidermis into the granulation, and the presence of a large arteriole at the base of the granulation-tissue. If the granula- tions are cut off, they are reproduced before the sluggish epithelium incloses the wound. Conditions of this character are frequently associated with chronic alveolar abscesses associated with pulpless teeth. ULCERATION. og The liciiiorrliagic ulcer is one which bleeds upon the least provoca- tion. It is most frequently seen in scurvy. The ulcerating surface has a characteristic livid blue color, and the granulations possess an active tendency toward disintegration. Vicarious hemorrhage has been observed in cases in which there has been an arrest of the bleed- ing from hemorrhoids, and following a suppression of the menses. Torpid ulcers are those which show no active tendencies in any direction. They are seen most often in individuals suffering from the debilitating effects of acute or chronic disease, resulting in defective nutrition and impaired or diminished blood-supply to the affected part. The characteristic color of the granulation is pale red, and the pus which is formed is thin and watery. The callous ulcer presents a dirty, granulating surface, with thin, muco-purulent pus, and edges raised considerably above the surface. The skin is indurated and fixed for some distance around the ulcer. This form of ulcer exists without material change in size for a long time, and it is most often seen in connection with old varicose ulcers of the legs. Corroding ulcer is one which causes a progressive destruction of the soft tissues, usually starting in the form of a cutaneous affection which assumes the form of a boil — Delhi boil — and afterward ulcer- ates, causing considerable loss of tissue. Ulcers associated with lupus may also be classed with this form, as it shows a slow but constant tendency to spread to adjacent cutaneous tissue. Perforating ulcer (round ulcer) is an ulcerative condition of the stomach, usually dependent upon local obstruction of the blood-vessels of that organ. Its most common location is the posterior wall of the pyloric portion of the stomach. The perforation through the serous coat of the stomach wall has the appearance of having been punched out or cut out, and is usually round. Phagedenic ulcer is one which spreads rapidly, causing consider- able loss of tissue, and accompanied by great local irritation. It usually occurs in persons who are broken down by disease, lack of proper nourishment, or debauchery, and is seen most often in epi- demics of hospital gangrene, in ulcers which have been treated by irritating or escharotic substances, and in mercurial ptyalism. The primary syphilitic lesion sometimes takes on a phagedenic form, when it becomes very obstinate to the effect of remedial agents. Malignant ulcers are those which run a rapid course, spread in all directions, perforating the soft parts, and causing extensive gangrene and sloughing, with necrosis of bone. The constitutional symptoms which accompany this type of ulcei; are often profound, and not infre- quently terminate fatally. The class of individuals in whom this form of ulcer is most commonlv found are children who have suffered from 90 SURGERY OF THE FACE, MOUTH, AND JAWS. long and exhausting illness, or whose surroundings are unhealthy, and the food scanty and unwholesome. The parts most frequently attacked are the lips, cheeks, and gums. Noma or gangrena oris is an example of this type of ulcer. It is also associated with epithelioma and with carcinoma in other portions of the body. The exciting causes are irritations of a physical, chemical, or septic nature. The forms of ulcers most interesting to the oral surgeon, and which most frequently come under his observation, are simple fol- licular ulceration of the mucous membrane, aphthae, syphilitic mucous patches, deep syphilitic ulcerations, sloughing phagedena following mercurial ptyalism and scurvy, cancrum oris, gangrena oris, ulcera- tion associated with cancerous growths, and lupus. Healing.- — The process of healing in ulceration is by granulation and cicatrization. During the process of healing the dead parts of the ulcer come away as a thin, ichorous discharge, the exudates beneath and around become vascularized, and capillary loops shoot up toward the surface. Large numbers of leucocytes cluster around these, forming a surface of healthy granulation, which then discharge a thin, creamy pus, the laudable pus of the old writers. Cicatrization is the process of covering or skinning over the new tissue formed by granulation. During this process the surrounding surface of the skin sinks to the level of the granulation, the epithelial cells at the edge of the ulcer undergo segmentation or karyokinesis, and grow toward the center of the ulcer. This is denoted by a blue film, and while this is extending the new tissue of the ulcer is contract- ing from the conversion of the leucocytes into fibrous tissue. Con- traction does not stop with the healing of the ulcer, but continues for a considerable period afterward, and sometimes causes very great deformity. A cicatrix has neither nerves, glands, lymphatics, nor hair, and when injured it does not heal readily, and is prone to ulceration. Prognosis. — The prognosis of an ulcer depends upon several fac- tors, viz: The nature and primary cause, the situation, the age and constitution of the patient, and the complications. The complication most likely to occur is septic infection. Like open wounds, ulcers are constantly exposed to this danger, and when the fact of neglect and filthiness, as often seen in the out-patients who visit the infirmaries in our large cities, is taken into consideration, it seems wonderful that more cases are not complicated with some form of septic poisoning. The erysipelatous streptococcus is a frequent cause of septic infection of ulcers, and is most commonly seen among ignorant individuals who are filthy in their habits. Cases of this character may have progressed to such an extent before they are seen by the surgeon as to render treatment of no avail, and a fatal termination is quickly reached. ULCERATION. 9I Adenitis resulting in extensive suppuration of the glands from sepsis is another form of complication which may terminate in death from hectic fever, exhaustion, and amyloid degeneration of the liver and kidneys. (Minot.) The most important and dangerous complication is perforation of some important internal viscus, like the stomach, intestines, or bladder, which establishes septic inflammation of the peritoneal cavity; or malignant and syphilitic ulcers, which perforate the cheek or palate and nasal septum. Peritonitis is the inevitable consequence of perfor- ation of an internal viscus in those cases in which the ulcerative process has been rapid. When the ulceration progresses more slowly, nature attempts to prevent perforation by establishing a plastic inflammation and thickening of the outer wall of the viscus at the base of the ulcer, and also of the peritoneum lining the abdominal walls, or covering some adjacent organ, resulting in adhesion of the surface in contact with it, and perforation of the wall of the adherent organ without enter- ing the peritoneal cavity. Hemorrhage is sometimes a serious complication, calling for liga- tion of the arterial trunk supplying the locality of the ulcer. This is most likely to occur in malignant ulcers, ulceration associated with malignant tumors, and in ulceration of varicose veins of the leg. The severity of the hemorrhage may be such as to endanger life. Hem- orrhages occurring in ulcers upon the surface of internal organs are often fatal from their inaccessibility to surgical treatment. Ordinary ulcers of the skin and mucous membrane of traumatic or idiopathic origin are never dangerous to life except through septic infection. The curability of an ulcer will depend largely upon the nutrition of the part, the character of the treatment, and the amount of care exercised in carrying out its details. Treatment. — The treatment of ulcers in general must be directed both to the local and constitutional conditions. The local treatment consists primarily in improving the circulation of the part. Passive hyperemia usually exists, and it is necessary to relieve this condition in order that the parts may regain their normal function, and thus be enabled to carry out the process of repair. (Warren.) Ulcers as they come under the observation of the surgeon are usually more or less in a state of inflammation from the presence of micro-organisms or other irritating substances which prevent the establishment of the healing process. Rational treatment would therefore be directed first to the removal of the cause of irritation, and the adoption of means which would relieve the inflammatory symp- toms. These ends may be accomplished by rest of the part, cleanli- ness, antiseptic compresses saturated with hot antiseptic solutions, antiseptic dressings, and, if the disease is located in an extremity, ele- 92 SURGERY OF THE FACE, MOUTH, AND JAWS. vation of the limb to a higher level than the rest of the body, as this favors relief of the hyperemic condition of the part. Rest in bed is always advisable in an}' case of serious ulceration. Care must be ex- ercised, when using moist compresses and dressings, that the tissues are not injured by too long an application at one time; twenty-four to thirty-six hours is as long as the tissues should be subjected to this kind of treatment without intermission. In addition to the above treatment, accumulations of pus in the cellular tissue or adjacent glands should be evacuated by free incisions and the establishment of ample drainage. If erysipelas is present it is best to treat this condition by the use of wet compresses wrung out of hot bichlorid solution of the strength of one to one thousand, or one to two thousand, in water. In a majority of cases an ordinary ulcer will begin to heal as soon as the inflammatory symptoms have subsided. Indolent ulcers may be stimulated by the application of balsam of Peru, nitrate of silver, alum, permanganate of potash, sulfate of copper or zinc, chromic acid, iodin, boric acid, and ichthyol. Numerous drugs have been recommended for their stimulating qualities, but the above mentioned are sufficient to indicate this class of remedies. Balsam of Peru is an excellent remedy and one of the oldest for stimulating the growth of granulations in that class of external chronic ulcers and granulating wounds in poorly nourished individuals in which the process of healing has been established, but progresses very slowly. Nitrate of silver is used in solution of 5 to 10 grains to the fluid- ounce of water, as a stimulating application to ulcers of the mucous membrane. It is also used in stick form, freely applied, for the pur- pose of destroying unhealthy granulations. To stimulate the base of the ulcer it may be lightly applied so as to leave only the slightest evidence of an eschar. Alum applied in powder or solution acts through its irritating and astringent properties. Permanganate of potash, in solution of from 5 to 10 grains to the fluidounce, is an excellent stimulant to chronic ulcers, but sometimes these strengths will prove painful, and weaker solutions must be used. Solutions of copper and zinc sulfate of about the same strength often prove themselves to be valuable remedies in the same class of cases. Chromic acid is of value in secondary syphilitic ulcers of the mucous membrane, especially of the mouth, and in noma. A solution of 10 grains to the fluidounce of water will sometimes cause the former to heal without the aid of constitutional treatment. In noma it is claimed to be beneficial b}' destroying the diseased tissue, and thus giving opportunity for the formation of healthy granulations, but in the writer's experience nothing has proved of permanent benefit in cases of true noma. ULCER.\TION. 93 lodin and iodoform are the best remedies in tubercular ulcers. Boric acid has a wide range of usefulness in the treatment of al! forms of ulcers, being antiseptic as well as stimulating. Ichthyol was introduced to the profession by Unna as a stimu- lant to the growth of epithelium, but it is also a valuable aid to the growth of granulations. It may be employed in a lo per cent, solu- tion, but it is most commonly applied in the form of an ointment of a 25 per cent, strength. Operative Treatment. — Skin-grafting and plastic flap operations are sometimes employed to close extensive open wounds and ulcers, caused by loss of tissue from surgical operations and other trauma- tisms, particularly those following burns and scalds. The Thiersch method of skin-grafting is generally considered the best, and consists of cutting thin shavings of healthy skin from an arm or a leg, and applying them to the surface of the ulcer or granulating wound, which has been-previously prepared to receive them by removing the granu- lations and arresting the hemorrhage. The grafts are then gently- pressed down and held in position by cotton dressing saturated with a salt solution, and protected by rubber tissue and a bandage. The dressing is changed in twenty-four hours, and renewed as often as the case requires. Antiseptic solutions are not used, but the dressings are kept moist with a sterilized salt solution. Large surfaces are frequently covered at a single sitting by this method. Plastic flap operations are sometimes utilized to cover granula- tions of moderate size, and to fill gaps caused by the loss of tissue in the removal of tumors. These flaps are taken from adjacent tissue, but always in such a way as to leave a broad pedicle through which the flap is nourished until such time as union takes place between the flap and the granulating surface. The flap is stitched to the edges of the ulcer after they have been freshened, and it is then treated as a recent wound. Sponge-grafting is another method of hastening the process of healing of ulcers and granulating wounds. The sponge is prepared by first decalcifying it by soaking in nitro-hydrochloric acid, and then washing it in an alkaline solution to remove the acid and preserving it in a one to twenty solution of carbolic acid. When applied to the granulating surface it is first cut into a thin piece of the exact shape of the opening to be filled, and after careful disinfection of the ulcer and its surroundings it is placed in position, and covered with anti- septic dressings, which will require frequent renewal on account of the decomposition which usually occurs. After a few days the granula- tions will spring up and fill the interstices of the sponge, finally reaching the surface, and the sponge will be buried out of sight; the process of covering with epidermis will then begin. The sponge is 94 SURGERY OF THE FACE, MOUTH, AND JAWS. afterward absorbed. The late Dr. William H. Atkinson, of New York, Brock, of St. Louis, and others, made extensive use of this method of healing ulcers of the mouth, and reproducing tissue lost by accident or surgical operations. Constitutional Treatment. — The constitutional treatment of ulcers must be directed to the systemic condition which operated as the predisposing cause of the affection. It may not be possible in all cases to determine or discover the evidence of a general disorder, or taint of the system, but, when such a taint can be detected, appropriate reme- dies must be administered for its eradication. Syphilis will require appropriate specific treatment accompanied with tonics. Tuberculosis will require rest, change of climate, and remedies which will build up and support the strength of the patient. Anemia and diabetes are frequently predisposing causes of ulcer, and should not be overlooked when searching for a constitutional cause for the ulceration. Gouty affections are often associated with vascular changes and ulceration of the skin and pericemental tissue. This condition should be sought for, and, if present, measures must be taken to improve the general condition, such as vegetable diet, abstinence from wines and malt liquors, etc. In many cases of chronic ulcers, no constitutional pre- disposing or other cause can be discovered, and nothing remains in the line of constitutional treatment beyond the observance of simple hygienic rules of life, the administration of tonics, and change of sur- rounding's. REVIEW. CHAPTER VIII. What is an ulcer? To what does it owe its existence? What is the difference between a granulating wound and an ulcer? How is tliis difference explained? Under what conditions may a granulating wound become an ulcer? What is the difference between ulceration and gangrene? By what process do wounds heal which have failed to unite by first inten- tion? Of what is a granulation composed? What are the characteristics of healthy granulations? What are the characteristics of an ulcer as to its size, its edges, its base, and its surface? What is the character of the tissue left by healing? What are the pathologic conditions of an ulcer as revealed by the micro- scope? With what other conditions is the ulcerative process intimately con- nected? How are the causes divided? ULCERATION. 95 What are the predisposing causes? What are the exciting or active causes? What influence does age exercise in the etiology of ulcers? How does old age predispose to ulceration? What influence does sex exercise in their production? What is the difference in ratio? How is this diflference explained? What is the influence of occupation in the production of ulceration? What influence have neglect and filth in their production? Name the most frequent cause of acute ulceration. What constitutional conditions predispose to ulceration? How are ulcers classified? Into what general forms are they divided? What varieties are classed as non-infectious? What as infectious? Which form is the most common? What is the usual condition of exposed ulcerated surfaces? How is the inflammatory process established? What other conditions in the character of ulcers form a basis of classifi- cation? Name the varieties. What is an inflamed ulcer? Describe its appearance. What is an erethistic ulcer? Where is it most frequently located? Describe its appearance. What causes the hyper-sensitiveness? With what constitutional conditions is it often associated? What is a ftmgous ulcer? How are the fungous granulations produced? What retards the process of healing? Of what are fungous granulations an evidence when found protruding from 3. fistulous tract? From what is the mushroom-like granulation due? What is hemorrhagic ulcer? How may it be distinguished? Under what conditions has it been observed to possess a vicarious func- tion ? Describe a torpid ulcer. In what class of individuals is this form most common? How may a callous ulcer be distinguished? In what connection is it most often seen? Describe a corroding ulcer. With what other condition is it sometimes associated? What is a perforating ulcer? Where is it most commonly located? What is the appearance of the ulcer? What is a phagedenic ulcer? In what class of individuals, and under what circumstances, is it most com- monly seen? What class of syphilitic lesions sometimes take on this form of ulceration? What is a malignant ulcer? What is the character of the constitutional symptoms? 96 SURGERY OF THE FACE, MOUTH, AND JAWS. How does it frequently terminate? In whom is it most commonly found? Under what conditions? Where is it most frequently located? Give an example of this form of ulcer. With what form of tumors is it sometimes associated? Name the forms of ulceration most common in the mouth. How do ulcers heal? What term is applied to the tissue formed by granulation? What anatomical elements are not found in cicatricial tissue? Upon what does the prognosis of ulcers depend? What is the most common complication? What forms of septic infection sometimes prove fatal? What is the most important and dangerous complication? In perforation of an internal viscus, what is the result? How does nature sometimes prevent perforation into the peritoneal cavity? In what form of ulceration may dangerous hemorrhage occur? Under what circumstances might it prove fatal? What is the prognosis of ordinary ulcers of the skin and mucous mem- brane? Upon what will the curability of an ulcer largely depend? To what conditions must the treatment be directed? What special condition must first be relieved in order to establish the process of repair? What is the usual condition of ulcers, and what are the causes? How may these conditions be removed? What is the danger of long-continued moist dressings? When suppuration is present, what is the treatment? When complicated with erysipelas, what is the treatment? Name the remedies used to stimulate the healing process of ulcers. In what class of cases is balsam of Peru advantageous? In what form of ulcer is nitrate of silver most valuable, and how is it applied? Through what properties does alum produce beneficial efifects? In what form of ulcers is the permanganate of potash useful, and in what strength? Sulfates of copper and of zinc are useful in what class of cases, and in what strength may they be applied? Under what circumstances and in what strength is chromic acid used? In what form of ulcer are iodin and iodoform used? When is boric acid useful? What is the value of ichthyol ? How may it be employed? What operative measures are used to cover ulcerated surfaces? Describe the Thiersch method of skin-grafting. How is the flap operation made? What is the after-treatment? Describe the method of sponge-grafting. What is the line of constitutional treatment in ulcers? How should a syphilitic condition be treated? What is the treatment in tubercular disease? When no constitutional taint can be discovered, what treatment should be followed to build up the system? CHAPTER IX. NECROSIS. CARIES, AND GANGRENE. Necrosis, Caries, and Gangrene are conditions, not diseases. These forms of death occurring in tissues, and organs, and in cells and cell grotips, are termed local death, or necrosis, in contra- distinction to somatic death or death of the whole organism. The causes which lead to local death of tissues may be divided into three groups. The first includes those which destroy the tissues by me- chanical or chemical action; for instance, external violence, which may crttsh a finger or a toe; sulfuric acid or caustic potash, which may destroy a patch of skin; or micro-organisms, which may disorganize the structure of a gland to which they have gained access. The second group of injuries may be classed as thermal, and are dependent upon high or low degrees of temperature. If the temperature of the tissue be raised to 130° F., or 140° F., and maintained at that degree for any length of time, death of the tissue is the inevitable result. Higher temperatures act still more rapidly. The lower limit within which the life of tissues may be maintained for any considerable period is 60° to 64° F. (Ziegler.) The third group are those which arise from arrestation of the circulation and nutrient functions. All condi- tions which seriously interfere with the circulation so as to bring about stasis, such as inflammation, hemorrhage, extravasation, pressure upon the tissues, thrombosis, embolism, or closure of the vessels by disease or ligation, may lead to death of the affected tissue. It is possible for all three of these groups to act together or successively. The effect upon the tissues of a given injury in producing local death will depend upon the condition of the tissues at the time of the injury, their power of resistance, and the condition of the general organism. Tissues which have been the seat of a pre-existing in- flammation, or any other condition which has lowered their powers of vital resistance, succumb more readily to injuries which produce necrosis, caries, and gangrene than normal tissues. When through disease the vital powers of the general system have been reduced, slight injuries will often cause serious consequences. In persons suf- fering from uncompensated valvular disease of the heart, slight injury may induce gangrene of the limbs. In patients emaciated from S 9- 98 SURGERY OF THE FACE, MOUTH, AND JAWS. typhoid fever, slight pressure upon the skin over the trochanter, elbow, sacrum, or heels may induce mortification of the skin and subcutan- eous tissues. It is interesting to note the time required to produce death in the various tissues of the body by the arrestation of the blood-current. The period varies in different tissues. Brain-tissue, renal epithelium, and intestinal epithelium die in two hours. Skin, bone, and connec- tive tissue continue to live over twelve hours. (Cohnheim.) Tissues which exercise special functions die more quickly than those which do not exercise such functions. These facts should govern all operations for the transplantation or replantation of tissues. Success is more likely to crown the effort in transplanting and replanting of teeth if the operation is completed within an hour or two after the extraction of the tooth. Necrosis. Definition. — A'ccrosis (from the Greek •jskpo's, dead). Necrosis is death en masse of bone-tissue. The term necrosis signifies the condition of death. When used in its technical sense, it refers to the process of death, or "the sum of the actions which terminate in the death of a portion of the skeleton, osseous or cartilaginous." (Markoe.) It is evident, therefore, that the term does not stand for a particular disease, but for a condition or result following" many forms of disease associated with the bone. It has become common practice, however, with surgeons and patholo- gists to use the name applied to this condition or symptom as the one most convenient and best suited to designate the affection of which it is at most only an accidental consequence, and yet one that is very prone to occur as a result of certain injuries and diseased conditions affecting the bones or the tissues immediately connected with them. The degree of injur}-, whether traumatic or idiopathic, necessary to cause necrosis of bone, is much less than is required to produce death of the soft tissues. This may be explained by the fact that the exter- nal or superficial layers of the bone are supplied vnt\\ blood through numberless small vessels given off from the deeper portions of the periosteum. Separation of the periosteum from the bone is very liable to occur, and may be brought about in various ways; for example, it may be stripped from the bone by violence, either accidental or surgi- cal; it may be lifted from its attachment by effusion of blood, resulting from injury, or from the effusion of serum or other inflammatory product, especially pus. Another reason which may be advanced to account for the readiness with which bone-tissue succumbs to inflam- matory processes is found in the compact tissue of the bone itself. "The Haversian canals are filled completely by the vessels which run NECROSIS, CARIES, AND GANGRENE. 99 into tlieni, and b}- the cell structures which are packed tightly around these vessels, so that when the inflammatory stimulus calls for larger blood-currents and more blood-cells, there is no room for the enlarge- ment of vessels thus imperative]}^ demanded, and the consequence is that the vessels, not having the power to accommodate themselves to this new and sudden demand, become choked, stasis occurs, and, as a consequence, those portions of the bone most deeply involved die." (Markoe.) Death of dentine occurs in the same manner by strangula- tion of the dental pulp. In speaking of local death of tissue, the devitalized portion of bone is called a sequestrum, the dead portion of soft tissue is called a slougli. These considerations very naturally lead up to and suggest the causes of necrosis. Causes. — Necrosis or death of bone-tissue is the result of condi- tions which have impaired or entirel}' arrested the supply of blood to the part, like traumatisms, inflammatory conditions resulting from syphilis, mercurial ptyalism, poisoning from phosphorus or other toxic substances, extensive inflammation from neighboring parts, or any other cause which produces a lowered vitality of the tissues. Death of the bone may be confined to small portions, or it may in- volve an entire bone. Fragments of bone which have lost their vas- cular connection may also become the seat of necrosis. Fractures, and periostitis the result' of specific infection, or the constitutional efifects of certain drugs, are the most frequent causes of necrosis. The dead portion of bone, when not already separated from the living tissues, later becomes detached in consequence of the formation of granulation-tissue between the dead and living portions, and even- tually the disintegration of this tissue leaves the necrosed portion sep- arated. The process of separation is generally slow and tedious, and if the necrosed part is deeply situated its exfoliation may be long de- layed. The structure of the dead portion is still preserved, so that there is no difficulty in its recognition. Suppuration is always present, and around the necrosed bone there is an accumulation of a fetid, purulent fluid, containing broken-down tissue, debris the result of decomposition and of the inflammatory process, which by degrees burrows the tissues, and eventually reaches the surface. A sequestrum of necrosed bone is porous, and somewhat lighter than living bone, owing to the fact that the organic elements have been removed from it by the process of decomposition and the action of the granulation- tissues which surrounded it. The treatment of necrosis and caries will be considered in the chapter on Necrosis of the Jaws. 100 surgery of the face, mouth, and jaws. Caries. Definition. — Caries (Lat. caries, rottenness). A chronic inflammation of bone, with rarefaction or absorption of bone-tissue, followed usually by pus formation; molecular death of bone, with the accompanying process ; sometimes termed ulceration of the bone. The term caries is applied to a molecular death and disintegration of bone-tissue. The two forms of death of bone — necrosis and caries — are to the osseous tissue what gangrene and ulceration are to the soft tissues. Necrosis and caries of bone may be distinguished clin- ically from each other by the difference in the sound given off when percussed (the percussion note), and by the difference in the degree of density. Upon probing the opening in the external tissues of necrosed bone, it wih be recognized by its hardness, and the sharp percussion note when struck with an instrument, while caries of bone will give a dull sound, and permit the penetration of the instrument into its structure. Causes. — Caries of bone is a chronic inflammatory condition, in- duced almost always by tubercular or syphilitic infection. The tuber- cular form occurs most frequently at the epiphyseal ends of the long bones, in the bodies of the vertebrse, and occasionally in the bones of the face, the lower jaw most frequently. The syphilitic form is most commonly seen in the bones of the nose and palate. In the tuber- cular form the affection usually causes the formation of abscesses, which may burrow and open at some distance from the seat of a tuber- cular disease. Upon exposing the diseased portion of the bone it will be found to be softened, disintegrated, while portions have been re- moved by liquefaction or absorption, leaving a cavity of greater or less extent, the surface of which will be covered by granulation-tissue and e.suding pus. If the process has been rapid, small spiculse of necrosed bone will be found entangled in the granulations or mixed with the pus. In syphilitic caries, especially of the bones of the nose and palate, the external covering of the bone will usually have disappeared from ulceration, leaving a granulating surface, discharging the character- istic gummy pus. Gangrene. Definition. — Gangrene (Gr. ydyyjKv.-ja, a sore, and yinuvsv^, to gnaw). Mortification or death of a part of the body from failure in nutri- tion, death en masse of soft tissue. The putrefactive fermentation of a dead limb or tissue. Gangrene presents itself in two forms. The first is designated as dry or senile gangrene; the other as moist gangrene. NECROSIS, CARIES, AND GANGRENE. lOI One of the first changes which takes place in the tissues after the death of the part is the disappearance of the nuclei of the cells. In some cases the nuclei become granular, probably from the breaking up of the chromatin — the delicate reticular structure of the nuclei — or the material which is most susceptible to staining agents, and passes from the nucleus into the protoplasm or body of the cells, where it is dis- solved and disappears. In other cases the nucleus itself seems to lose its susceptibility to the staining fluids, is dissolved, and disappears. Th.ese changes take place after closure of a vessel by embolism, and are readily seen in the epithelium of the kidneys under such circum- stances. The color of the tissue of the organ is also changed to a pale, cloudy, yellowish-white appearance. (Warren.) "Coagulation-necrosis" (Weigert) may sometimes take place, and the cellular elements be transformed into granular or hyaline masses, with loss of their nuclei. Hyaline degeneration (a conversion of tissue to a clear, transparent, jelly-like material) often attacks the inter- cellular structure of the tissues. This change is seen in muscle fiber when death has taken place from toxic infection, a burn, or other trauma. Death of tissue accompanied by coagulation occurs in two ways. One kind occurs in certain of the vital fluids like the blood and lymph, and in fluids which have escaped from the vessels, by the formation of granular, fibrous, or homogeneous coagula. In the other, cells and intercellular structures, as they die, become solid and firm, and form by coalescence peculiar homogeneous or hyaline masses. (Ziegler.) The coagulation of blood or of lymph, according to current opin- ion, occurs when the white blood-corpuscles die and are dissolved in the plasma, and the granular, fibrous, and hyaline masses which appear are albuminoid in character, and are designated in general terms as fibrin. To bring about coagulation, — in other words, the formation of fibrin, — the presence of fibrinoplastin (a native proteid obtained from the blood-serum) and a ferment is necessary. Both of these substances are supplied by the white blood-cells as they die and are dissolved in the plasma. Inflammatory exudates and effusions may coagulate in the same manner, forming masses which are rich in fibrin. False membranes are formed in this way upon the surfaces of inflamed tissue. In the second form of death of tissues, the circumstances and appearances are essentially dififerent from those of the first. Coagula- tion of the albuminoids has taken place in this form as in the other, but with this difference, that the coagulation has occurred in the substance of the formed tissue elements, the cells and intercellular substance, instead of in a fluid. It is necessary, however, in order to produce this form of coagulation, that a moderate amount of lymph shall flow through the dead portion of tissue. The lymph con- I02 SURGERY OF THE FACE, MOUTH, AND JA^^•S. tains fibrinogen, the cells fibrino-plastin, and by a combination of these substances fibrin is produced, resulting in coagulation-necrosis. Coagulation of the dead cells is not so likeh' to occur in tissues in which the process of death has been protracted, for the reason that degenerative changes may be established, like fatty degeneration, and thus render the cells non-coagulative. Similar cell changes to those which occur in coagulation-necrosis, and particularly the loss of the nuclei, may result from the process of putrefaction. Causes. — Gangrene is so intimately associated with certain changes in the arterial system that it will be necessary' to mention some of the conditions which are liable to produce it. Among the most fre- quent of these conditions is inflammation of the walls of the arteries. Arteritis is almost always followed by the production of new tissue within the walls of the vessel, and this holds an important relationship to the degree of freedom with which the blood circulates through the diseased vessels. In the aorta and large arteries, this new formation assumes the form of warty or pediculated projections, which in the smaller arteries may involve them for a considerable distance, and be so extensive as to more or less completely close the lumen or caliber of the vessel, and which is termed "obliterating endarteritis" (\\^arren), and thus greatly impede the flow of blood or arrest it altogether. Atheromatous degeneration is a not infrequent termination of many cases of inflammation. It begins in this particular form by the formation upon the inner wall of the vessel of soft, gelatinous nodules, which after a time become quite hard, but later show signs of degenera- tion, and upon cutting them open they are found to contain masses of whitish or yellowish material. These masses finally soften, resulting in atheromatous ulcers, or, according to Orth, if the mass be seated deeper in the wall of the vessel, a cavity may be formed containing fatty granules, fragments of tissue, etc., and forming an "atheromatous abscess," which may eventually discharge its contents into the interior of the vessel. Thrombi sometimes form at the location of these ab- scess cavities or open ulcers. In the smaller vessels, these ulcers may result in a complete obliteration of the lumen of the vessel. Calci- fication sometimes takes place in the atheromatous foci, and these masses, covered with epithelium, may be present in large numbers in the aorta and large arteries, or they may be found projecting from atheromatous ulcers. Syphilis and tubercle also produce changes in the walls of the arteries which impair their function of nutrition. The effect of these changes coming late in life must be very great upon the arterial circulation of the extremities, as there is naturally at this time an enfeeblement of the circulation in these localities. If the disease has been confined to the smaller vessels, the circulation has been grad- ually diminished, and finalh' ceases, as the result of the formation of a NECROSIS, CARIES, AND GANGREXE. IO3 small thrombus, or of some insignificant traumatism. Tlie obliteration of the lumen of the artery cuts ofif all fluid from the dead part, and, as the disease has not been connected with the veins, they have been unobstructed, and have carried off the venous blood in the part; con- sequently the dead tissue becomes dried from evaporation, and the condition is produced which is known as dry or senile gangrene. \Mien death of a portion of the soft tissue takes place, there is always, as a constant result, a more or less severe inflammation in the surrounding p'art, which is most severe when decomposition has taken place in the dead portion. Decomposition is due to the action of the saprophytic germs. By means of this surroimding inflammation — the inflammatory zone — the dead portion is differentiated and isolated from the rest. The inflammation is therefore described as definitive, . and the zone as the line of dcmarkation. The final terminations of death of soft tissues are generally classed under four main types. In the first class, the dead tissue is thrown of? or absorbed, and replaced by newly-formed tissue of the same character — normal tissue: this is termed healing by regeneration. In the second the dead tissue is likewise thrown off or absorbed, but is not replaced by tissue of the same character, but by a fibrous tissue, which fills up the gap in part or in whole. This is termed healing by scar or cicatrix. In the third, the dead tissue is only partially absorbed, a portion remaining as a caseous mass, which later may become calcified, and inclosed in a capsule of connective tissue. This is termed caseation and calcification. In the fourth, the dead tissues are also absorbed, and in their place there is developed over the boundary of the vacated space a small amount of fibrous tissue. In other instances this space becomes filled with fluid, which is thus encysted. This is termed encystment. (Ziegler.) Examples of this not infrequently occur in connection with severe pericementitis and alveolar abscesses. Dry Gangrene or Mummification. — This condition is usually the result of death of soft tissue in parts which are exposed to the air, and is caused by defective blood-supply from the general feebleness of the circulation, and local changes in the vessels themselves. Examples are senile gangrene of the toes and the feet. The affected part be- comes engorged with blood before its death takes place, and the color- ing matter transudes the tissues, and gives rise to a dark red or purple appearance. At the same time, the tissues begin to dry from evapora- tion. The part first becomes leathery, then perfectly hard, brittle, and black. Between the dead and the sound tissues there is always the inflammatory zone, or line of demarkation. Dry gangrene is often an aseptic gangrene. This form of gangrene is not usually attended with I04 SURGERY OF THE FACE, MOUTH, AND JAWS. any general constitutional symptoms. Attempts to remove the dead tissue should be postponed until separation takes place. Moist Gangrene. — This is death of soft tissue, followed by decom- position and putrefaction, which is brought about by the presence of micro-organisms. These organisms may reach the part either through the air or through the circulation. The putrefying tissue takes on the characteristic odor of putrid animal matter, disintegrates, and liquefies. Not infrequently gases are formed in the tissues during the process of disintegration, causing puffiness of the part, which crep- itates under pressure. This is termed emphysematous gangrene.- The condition is sometimes associated with alveolar abscess or severe crushing injuries of the soft tissues of the face, or it may result from ligating the facial artery, or by septic poisoning. Moist gangrene is necessarily a progressive gangrene. Symptoms. — The local symptoms are at first acute inflammation, with great congestion, and pain of an intense burning character. Later the pain ceases, followed by loss of sensation and of power to move the part. The local temperature falls below normal, and pulsa- tion in the arteries cannot be detected. The color, which at first was dusky red, gradually assumes a blue, purple, dirty brown, or black. Occasionally blebs are formed, and the superficial vessels are marked by lines of dark discoloration. Vitality, even at this stage, is not absolutely destroyed, and may still be restored; but if the cuticle sep- arates from the derma, and can be removed by lightly rubbing the part, and if there are crepitation, emphysema, and foul odor, there can no longer be doubt of the absolute death qf the part. The constitutional symptoms of gangrene are those of inflamma- tory fever of low type, with rapid, feeble pulse, and low delirium. Prognosis.— The prognosis must be based upon the etiology, the location, the extent of the disease which caused the gangrene, and the general condition of the patient. An acute, rapidly-spreading gangrene, especially of the face and head, should always be considered as an exceedingly grave condition. The danger arises from the introduction into the general circulation of soluble toxic substances or ptomaines. When the gangrene is of mycotic origin, and rapidly progressive in its character," — with or without emphysema, — it almost without ex- ception proves fatal, unless early and heroic treatment has been insti- tuted. Death results from septicemia through the introduction of pus- microbes or putrefactive bacteria. Noma (cancer aquaticns), or gangrenous ulceration of the cheek, is characterized by an exceedingly rapid destruction of the tissues. Very little is known of its etiology. Its favorite primary seat is the mucous membrane of the cheek, generally at some distance from the NECROSIS, CARIES, AND GANGRENE. , IO5 lips, and most often at the junction of the cheek with the gums; more frequently at the inferior gingivo-buccal fold than at the superior fold. It is generally confined to one side of the face. On this account, some have thought it to be caused by a disturbance of the nervous system. It is more likely to be of mycotic origin. No specific micro-organism has yet been found in noma. Lingard found long bacilli, and Ranke has found streptococci. Various other forms have been discovered, but their relations have not been determined. It attacks exclusively little children between the ages of two and eight years, who have been poorly nourished, or are sufitering from one of the eruptive fevers, typhus, or are of cachectic habit. It is rarely seen in this country except in districts the most unsanitary, but it is quite common in the large cities of Europe among the very poor. The disease often spreads very rapidly, quickly destroying the entire cheek. It is not, however, confined to the soft tissues, but at- tacks the maxillary bones, often causing extensive necrosis and loss of the teeth. The disease generally proves fatal in a few days. In one case which came under the notice of the writer at St. Luke's Hospital, the patient lived but five days; another just one week. Dry gangrene does not therefore present the serious conditions of the moist varieties, as it is not attended with the same dangers of septic intoxication. Hospital gangrene only occurs as an infection of wounds, and is seldom found outside of unsanitary and overcrowded hospitals. Before the introduction of antiseptic surgery it was quite common, especially in the military hospitals of Europe, and in our own during the War of the Rebellion. Billroth believed the disease was due to a specific micro- organism, which is only produced under certain atmospheric condi- tions; hence its epidemic form. There is no doubt that the disease is often carried from one patient to another by the sponges, instruments, the hands of the operators and nurses, and in the atmosphere. The fact that this terrible disease has been stamped out of the oldest and most unsanitary hospitals by the strict antiseptic treatment of wounds, would seem to be conclusive evidence that it is of mycotic origin. Treatment. — All patients suffering from gangrene are in a debili- tated condition, either from antecedent or concomitant causes, and are consequently unfavorably affected by the so-called antiphlogistic or sedative treatment. Fever is always the result of septic elements which have gained an entrance into the system; antipyretics are therefore not indicated, but effort should be made to remove the primary cause of the infection. This is the most important point in the whole line of treatment. Io6 SURGERY OF THE FACE, MOUTH, AND JAWS. The strength of the patient must be supported from the very be- ginning, by a generous diet and the use of stimulants. In case of feeble heart-action, digitalis is administered with benefit. The bitter tonics are often beneficial in improving the appetite. In all cases of gangrene of the face and oral cavity, the removal of the dead tissues should be accomplished just as soon as the line of demarkation has been established, not waiting for complete separation to take place. The partially separated tissue may be removed by the scissors and the curette, after which t"he wound resulting from such treatment may be cared for upon antiseptic principles. In cases of emphysematous gangrene, the gases and fluid should be evacuated just as soon as their presence is established, by numerous small incisions made over the affected area, care being taken not to injure important blood-vessels. Good drainage must be established and maintained so long as discharges are present. The most favorable symptom after operation in cases with septic intoxication is a reduction of the temperature within a few hours to the normal point. The removal of the tissue which had caused the septic poisoning, and the elimination of these toxic substances from the system through the excretory organs, produces a subsidence of the constitutional symptoms, and if the patient has sufficient strength to carry him through the shock of the operation, he has good prospects of an ultimate recovery. In noma and hospital gangrene, after the removal of the dead tissue with the scissors and curette, and thorough irrigation, the sur- faces of the wound should be seared with the electro-thermal cautery. Antiseptic conditions should be maintained in the after-treatment. This will be found to be somewhat difficult of accomplishment when the disease is associated with the oral cavity; but with care and per- sistent effort much may be done in this direction. Thiersch solution and boric acid solution are valuable antiseptics, and may be used with impunity in the oral cavity, without fear of toxic symptoms. REVIEW. CHAPTER IX. Are necrosis, caries, and gangrene diseases? Give the definition of each of these conditions. What is the distinction between this form of death and somatic death? What are the causes of necrosis, caries, and gangrene? Into how many groups are these causes divided? NECROSIS, CARIES, AND GANGRENE. IO7 What does the first group include? Name the classes of injuries of the second group. What is the eflfect of high and low temperature upon tissues? What conditions are included in the third group? Do these causes ever act together? What effect does the lowering of the vital powers have upon tissues when only slightly injured? How long will various tissues live after being cut off from their blood- supply? What is the efTect upon tissues having special functions? In transplanting or replanting teeth, how long a time may a tooth be out of the mouth with safety to the operation? When the term necrosis is used technically, to what does it refer? What is the difference in the degree of injury necessary to cause death in bone over that in soft tissue? How is this explained? What is another reason found in the bone itself? How does death of dentine occur? What terms are applied to the dead portions of bone and of soft tissues? ^^'hat are the causes of death of bone-tissue? ^^'hat are the variations in the extent of necrosis? What are the most common causes of necrosis? By what means is the process of separation accomplished between the living and dead tissue? Is it a slow or a rapid process? Is the structure of the dead bone changed? What inflammatory condition is always present? What is the character of the pus? Name the differences in the appearance between a sequestrum and living bone. How are these differences explained? What is caries? How does it differ from necrosis? By what means may they be distinguished from each other clinically? What are the causes of caries? Where are each of these forms commonly located? What are the local conditions of tubercular caries? What are the local appearances of syphilitic caries? What is gangrene? Into how man}' forms is gangrene divided? Name them. What changes take place in the tissue-cells soon after the death of a soft part? What other conditions may take place? What degenerative change may take place in the coagulated cellular ele- ments? In what kind of tissue is it seen? How does coagulation of blood or lymph occur? How does it occur in formed tissue elements and intercellular substance? Under what conditions ma}' coagulation not occur in the dead cells? What other process may result in the loss of the nuclei in the dead cells? What diseased condition of the arteries is intimately associated with gan- g'rene? I05 SURGERY OF THE FACE, MOUTH, AND JAWS. How does arteritis cause gangrene? How may atheromatous degeneration cause gangrene? What other diseases may produce changes in the walls of the arteries? How is "dry or senile" gangrene produced? What follows as a constant result of gangrene? When is this inflammation most severe? What is the cause of the decomposition? What is a definitive inflammation? What is the line of demarkation? The fixed terminations of dead soft tissue are classed under how many types? Describe these four conditions. What is dry gangrene? How is it caused? What is its appearance? Is this form of gangrene attended with constitutional symptoms? What is moist gangrene? How is it caused? What is emphysematous gangrene? What are the constitutional symptoms of gangrene? Describe the local symptoms. Upon what is the prognosis based? Is rapidly spreading gangrene dangerous? What is the usual termination of rapidlj' progressive gangrene? What is noma? What is its probable origin? Whom does it attack exclusively? Under what conditions is it commonly seen? What is the course and termination of the disease? How does hospital gangrene occur? What is its probable cause? How is the disease transmitted? What proves its mycotic origin? What is the usual condition of patients suffering from gangrene? How does an antiseptic or sedative treatment affect such cases? What is the cause of the fever? What is the most important step in the treatment? Of what should the constitutional treatment consist? What should be the line of treatment in gangrene of the oral cavity? How should cases of emphysematous gangrene be treated? What is the most favorable symptom after operation? How has the reduction of temperature been brought about? What is the treatment for noma? CHAPTER X. TRAUMATIC INFLAIVIMATORY FEVER. Definition. — Trmimatic fever is a reactive fever following shock from injury or operation. In shock following- injury the temperature falls below the normal ; when reaction sets in the temperature rises above the normal. As a general rule, the greater the shock the lower the temperature, and when reaction sets in the reactive ternperature will be correspondingly high. The fever usually develops a few hours after the injury, and generally subsides in from twenty-four to forty-eight hours. Traumatic fever may be aseptic or septic, the character depending upon the condition which prevailed at the time of the injury. Asepfie fever is a condition which accompanies the healing of wounds by first intention. An elevation of temperature from two to three degrees frequently accompanies the healing of woimds which have been treated antiseptically, but in which there is the formation of a considerable blood-clot between the lips of the wound, or in those cases where the bruising and manipulation of the tissues has been extensive. Attention has already been called to the fact that cer- tain chemical substances of a non-pyogenic nature were capable of causing a rise in the temperature when introduced into the circulation. Among these substances is a peculiar ferment, obtained from defibri- nated blood, known as "fibrin-ferment." This substance, when in- jected into animals, causes extensive coagulation of the blood, and death. The animal alkaloids or leucomaines produced by the construc- tive metabolism of the tissues which occurs in the healing of wounds are not unlikely active factors in the production of this form of fever. On the other hand, the leucomaines produced by the destructive metabo- lism, which takes place in minute portions of tissue, and in blood-clots remaining between the lips of wounds, may produce a like result. In aseptic fever, the only symptom of marked character is the elevation of the body temperature. This may reach 102° or even 104°, and not entirely disappear for several days. Patients suffering from this form of fever are rarely conscious of feeling unwell, and may be able to sit up in bed, or even move about the room. (Warren.) The conditions under which this form of fever is most commonly seen T09 ]IO SUKGERY OF THE FACE, MOUTH, AND JAWS. are in deep and extensive wounds which are healing by first intention ; in wounds closed without drainage; in simple fractures of the bones, and other subcutaneous injuries. Septic fever was supposed, before the introduction of antiseptic surgery, to be a natural consequence of the process of repair, as all wounds healed with more or less inflammation, even though suppura- tion was not established. The constitutional symptom of fever, which was sometimes very considerable, was called surgical or traumatic fever. We now know that these conditions were due to the presence of micro-organisms in the exudations of such wounds, which produced fermentative changes or decomposition, with the elaboration of pto- maines, the absorption of which caused an elevation of body tempera- ture or fever, by their poisonous effects upon the system. This type of fever is often seen to-day following wounds which have not been treated antiseptically, and in those injuries which have been exposed to infection, or in which infective material has been intro- duced. Examination of the blood taken from patients suffering from this type of fever reveals but few bacteria in this fluid, and when they are present rapid elimination or destruction takes place, so that they may entirely disappear in the course of two or three days. Progres- sive development of micro-organisms in the blood never takes place in this form of fever as it does in septicemia. A rigor followed by a sudden elevation of temperature, occurring on the first or second day after the injury, is indicative of septic poisoning and the formation of pus. A sudden fall of temperature, with a weak pulse, occurring at the same period, would indicate shock from internal hemorrhage, or collapse. Septic fever occurring in these days of antiseptic surgery is an evidence of either a slovenly operation; of deep-seated, penetrating or tortuous wounds, impossible to cleanse; wounds involving the peri- toneum, and of compound fractures of the bone in locations impossible to keep thoroughly clean ; as, for instance, in fractures of the maxillary bone of individuals who give no thought to the cleanliness of their mouths, or of infection of wounds by septic instruments, especially in the extraction of teeth. This form of fever generally appears on the second or third day after the injury or the infection, and lasts from two to six days. The constitutional symptoms are a sudden rise of temperature, ioo° to 102° F., skin hot and dry, the pulse rapid, and the tongue coated, accompanied with delirium or with digestive disturbances, heat, restlessness, and thirst. The urine is scanty and high colored, the bowels often constipated. The character of the evening tempera- ture is progressive. On the evening of the second day it may be 101°, the next morning drop one or two degrees, to again rise in the evening TRAUMATIC INFLAMMATORY FEVER. Ill to I02°, while on the fourth day it may reach 103°. These signs of constitutional irritation would certainly point to the presence of decomposition in the exuded material, the establishment of the suppu- rative process, or some form of infective inflammation. If suppuration takes place, pus is formed on the third or fourth day. The wound then cleans off, the ptomaines are washed away with the discharges, granu- lations spring up, and the system regains its normal temperature. Traumatic fever, suppurative fever, septicemia, and pyemia are all dependent upon the same causes, and are of the same nature, the only difference between them being one of degree. The symptoms, how- ever, are somewhat different. Suppurative fever, or "secondary fever," as it is sometimes called, is dependent upon the suppurative process, and is therefore a septic fever. It is, however, different from traumatic or surgical fever, for in this form the temperature falls as soon as pus is formed. Suppurative fever appears two or three days after the injury, and generally subsides at the end of the first week; but if the fever continues beyond this period, or if at the beginning of the second week there should be a sudden rise of temperature, with or without a rigor, this would be a good reason for suspecting the presence of pus at the point of injury. If the injury is at a point inaccessible to drainage, or difficult to reach with antiseptics, the high temperature will correspond in degree with the severity of the suppurative process; while on the other hand, if the pus can be reached and evacuated, and the wound treated antisep- tically, the temperature will soon subside and the general febrile symptoms disappear. It more commonly happens, however, when the infective inflam- mation is of an acute form, that the character of the fever will be of the continued type, with frequent exacerbations. The local symptoms, under proper treatment, become less acute, and eventually, as in joint and bone diseases, numerous sinuses are formed, communicating with the seat of suppuration, and from which pus freely discharges, thus establishing chronic suppuration. From this time forward the fever assumes the remittent type of suppurative fever, which consists of a normal or subnormal temperature in the morning, followed by a rise of from two to as high as six degrees in the afternoon, and accom- panied by the hectic flush and other signs of febrile disturbances. If the suppurative process is not checked, there will be considerable loss of flesh, great prostration, diarrhea, and profuse perspiration at night. Emaciation is progressive, bed-sores are developed, and the strength of the patient gradually fails, until it becomes only a question of how long the physical endurance will hold out. (Warren.) In chronic suppuration resulting from tubercular disease this form of fever mav continue for months, with increasing but more gradual 112 SURGERY OF THE FACE, MOUTH, AND JAWS. emaciation; and when death occurs, post-mortem examination of the internal organs shows extensive amyloid degeneration. These facts prove conclusively that the temperature is due to the continued absorp- tion of chemical substances elaborated in the wound by a destructive metabolism, or by the presence of the pus-producing micro-organisms. The clinical evidence of this lies in the fact already indicated, namely : That as soon as the supply of the pyogenic material is cut off by thor- ough drainage and antiseptic treatment, the febrile symptoms dis- appear. Suppurative fever of long continuance, if accompanied with great emaciation and prostration, would be a contra indication for a severe surgical operation, as in all probability there would exist extensive amyloid degeneration of the internal organs. Treatment. — The local treatment of traumatic inflammatory fever consists of freeing the wound of all tension, providing against the pos- sibility of the retention of the inflammatory discharges, irrigating thor- oughly with germicidal solutions, covering the wound with boric acid or iodoform, and the use of sterilized dressings, changed every day or twice a day if necessary. The constitutional treatment would be to clear the bowels by means of a saline cathartic, control the temperature with aconite or the antipyretic drugs; the pain by the use of morphia, and nervous excite- ment with bromid of potassium. The treatment of suppurative fever of either the acute or chronic type consists in the establishment of thorough drainage, and of disin- fection of the entire suppurating surface. To accomplish this the pus cavity must be laid open- by free incisions, and its walls thoroughly scraped with the curette. After the infective material has been scraped away the wound may be cleansed with antiseptic solutions, followed by peroxid of hydrogen, and again irrigated with the carbolic or bichlorid solution. When joints are diseased, amputation frequently ofifers a better chance of saving life than by resecting the joint. The constitutional treatment should consist of free stimulation, a nutritious diet, and tonics. Out-of-door life, if practicable, will many times bring about a decided improvement in the conditions. If the affection is the result of tuberculosis, the prognosis is most unfav- orable. REVIEW. CHAPTER X. What is traumatic fever? How does shock affect the temperature of the body? When reaction sets in, how is the temperature affected? TRAUMATIC INFLAMMATORY FEVER. II3 What relation does the degree of shock bear to the reactive temperature? When does the reactive fever develop? How long is its duration? What is aseptic fever? What degree of temperature often accompanies the healing of wounds? What is the explanation of the elevation of temperature in the healing of wounds? What is the effect of the "fibrin ferment" when injected subcutaneously in animals? M^hat other substances produced in the tissues may cause the elevation of temperature? By what two processes are these leucomaines produced? Are the leucomaines produced by the constructive and destnictive metabolism, pyogenic or non-pyogenic products? What symptom is generally the only marked one in aseptic fever? What is the condition of the patient at such time? Under what circumstances is this form of fever most commonly seen? What is septic fever? What are the causes of septic fever? Under what conditions is this form of fever usually seen to-day? Are micro-organisms found in the blood of such patients? What becomes of the micro-organisms? Are they ever found progressive in their development as in septicemia? Of what is a sudden rise of temperature indicative if it occurs upon the first or second day after an injury? Of what is a sudden fall of temperature associated with a weak pulse indica- tive? Of what is septic fever an evidence? How may infection occur in the extraction of teeth? When does this form of fever generally appear, and how long does it last? What are the constitutional symptoms? What is the character of the evening temperature? What degree of temperature may be reached upon the fourth day? Of what are these signs of constitutional irritation an evidence? What occurs upon the establishment of suppuration? What is suppurative fever? How does it dififer from traumatic or surgical fever? What is the character of the fever in the chronic form ? How is this form of fever expressed? Name the other symptoms of this form of fever. How does this form of suppurative fever differ from that caused by tuber- cular disease? What do these facts prove as to the septic nature of the disease? What are the clinical proofs of the same facts? Why should suppurative fever be a contra-indication for severe surgical operations? What is the local treatment of traumatic inflammatory fever? What is the constitutional treatment? How should suppurative fever be treated locally? What is the local treatment in joint-disease? What should be the constitutional treatment? CHAPTER XL SEPTICEMIA. Definition. — Septicemia (from the Greek fi-//-rf;o, putrid, and '/..',aa, blood). Septicemia is a disease or condition induced by the absorption of septic products; a form of blood-poisoning. Two forms of septic fever are still to be considered, viz: Septi- cemia and pyemia. Both of these conditions have been recognized ever since their description by Hippocrates, and on account of their dangerous and often fatal character have always been the subjects of anxious thought and investigation. Since the promulgation of the germ theory of disease, investigation and experimental research into the cause of these diseases have been greatly stimulated, and though it may not be said with positive assurance what the actual cause may be, yet such advancement has been made as to make it almost certain that they are due to the action of the micro-organisms of putrefaction, the saprophytic germs. Antiseptic surgery has here won another signal victory by preventing the development of these grave conditions, thereby saving thousands of lives that would otherwise have perished. Both of these conditions, however, are still occasionally seen in hos- pital wards, where thorough antisepsis has been neglected or has failed on account of the peculiar character of the wound, which has rendered it impossible to carry out the most approved methods; or by reason of the severity of the injury to the tissues, which has resulted in gangrene and sloughing. Billroth said, in speaking of these diseases, that septicemia bore the same relationship to surgical or traumatic fever that pyemia bears to suppurative fever, each being the malignant type of the correspond- ing milder affection. Surgical fever, as already stated, is developed in the earlier stages of the process of repair in wounds, before the establishment of the suppurative process, by the absorption of ptomaines elaborated in the wounded tissues 'as a result of ptitrefaction ; the fever subsides upon the formation of pus, which cleanses the wound and prevents further absorption by washing away the pyogenic substances. (Warren.) Septicemia is also dependent upon septic infection of the wound, 114 SEI'TICEMIA. 115 the absorption of poisonous substances resulting from decomposition, which produces a profound impression upon the system, and often terminates fatahy. The disease is therefore a malignant form of putrid infection, and is a sequel of a grave type of surgical or traumatic fever. It is seen most frequently as a comphcation of amputation wounds, severe crushing injuries, compound fractures of the long bones and of the lower jaw, acute osteomyelitis, deep tortuous wounds which it is impossible to treat by thorough antisepsis, gangrenous conditions of the tissues, wounds of the peritoneum, and in obstetrical cases from the retention and decomposition of blood-clots or placental debris within the uterus. It most often occurs in wounds in which the discharges aie abundant; the septic micro-organisms have had free access, and the process of putrefaction has been established. The disease is characterized by serious constitutional disturbances, such as high temperature, great prostration, disorders of the nervous system, inflammatory conditions of certain internal organs, accom- panied by typhoid symptoms and a tendency to heart-failure. Causes. — The nature of the toxic element which produces the dis- ease is not yet fully demonstrated, but it is generally accepted to be a product of the process of putrefaction, either in the form of ptomaines which are absorbed by the system, the introduction into the body and tissues of certain forms of micro-organisms which rapidly grow and multiply, or possibly of the introduction of some "ferment-like sub- stances" having the power of reproduction, and acting within the or- ganism like the poison of serpents, the virus of tetanus or of diph- theria. (Warren.) By experimentation upon animals it has been demonstrated that there are two varieties of septicemia, — one the result of poisoning by a chemical substance, and the other by the presence of bacteria in the blood. The first is termed sapreniia, toxemia, or septic intoxication. The second is termed mycosis or septic infection. In the first the symp- toms begin immediately upon the injection of the poison into the tis- sues, their intensity being governed by the size and the virulence of the dose, while in the second form the disease is developed after an inter- val, probably dependent upon the rapidity of the development and the multiplication of the bacteria in the blood, but progressing uninter- ruptedly to a fatal termination. Koch could not discover a constant bacterium in septicemia, and therefore concluded that those which were found in the blood were not the specific organism of the disease. The forms of bacteria usually found in septicemia in man are the staphylococci and the streptococci. Micro-organisms are, however, by no means always present in the blood in septicemia. Rosenbach found that blood-cul- tures taken from septicemia in man proved sterile. In these cases. Il6 SURGERY OF THE FACE, MOUTH, AND JAWS. however, he found the staphylococci present in the blood. He there- fore comes to the conclusion that the disease in man is usually the result of the absorption of ptomaines or ferments, and not of an inva- sion of the blood bj^ a specific micro-organism. Besser takes just the opposite view, and believes the disease is produced solely by the streptococcus. Clinically, the two forms of the disease just mentioned are also found in the human species. In the former there is an early absorption of the products of putrefaction, but the symptoms, as soon as further absorption of the poisonous substances is prevented by draining and cleansing the wound, rapidly disappear. In the latter the symptoms develop more slowly, and there are progressive changes established which often continue to a fatal termination in spite of all efforts by antiseptic treatment of the wound. This form is doubtless due to the presence of micro-organisms in the blood, although their demon- stration is not always possible. Gussenbauer thinks that there is fre- quently a mixture of these two types of the disease. Avenues of Infection. — The avemies through zdiich infection may enter the system are: septic wounds, accompanied by gangrene and sloughing; this is the most common mode of infection, though the disease may appear in its malignant form from even a very slight and insignificant wound, in which the putrefactive process has been estab- lished, or bacteria have multiplied and been diffused through the system. Septic infection sometimes accompanies other traumatic infective diseases, like erysipelas and hospital gangrene. Infection may also take place through the mucous membrane of the intestinal tract. The intestinal canal is always loaded with the various micro- organisms of disease, and under favorable conditions represented by enfeebled health they may gain access to the tissues and blood, and, as pointed out by Cheyne, a local injury or inflammation may furnish the proper soil for the development and multiplication of these wandering bacteria, and thus an infective inflammation will be established, fol- lowed by general infection of the system. The genito-urinary tract, when in a normal condition, is rarely an avenue through which infection takes place. The uterus immediately following parturition is a quite common avenue of infection, and many lives have heretofore been lost through ignorance of or an imperfect knowledge of this fact. The respiratory mucous membrane is gen- erally considered to be proof against the entrance of putrefactive infec- tion, as is also the skin, when it is in a normal condition. Fig. 35 is a culture from "Sputum Septicemia," Bronchitis putrida, or fetid bron- chitis resulting from gangrene of portions of the lung. Sapremia, — Sapremia, or the toxic form of septicemia, is most frequently observed in obstetrical wards and lying-in hospitals, and is Slil'TICEMlA. 117 due to putrefaction of blooil-clots and fragments of placenta retaine '^<^ ■ < > - -^ l^- ,,• * ^i* 4^^&ir "^ Polynuclear ' ■ V ''"'^'^rfk^ leucocyte. IHHL^^HiflHfiKSS^ " iSr^^rVm^*^ ^uHr i ^Hnt>- 1^' '* , ^ ^■^' '■'tiks VIononuclear BHMBBWELfc-- • leucocyte. MH^^^^^HHflgjgirjr^ * ^^^^HHHH^^Pa' Periosteal ^^^^^P^^iP^ ' "'^■^ ' <• fibers. ^B^^HlUr^V' N» : ^^HKuiifaAMiuiiv.^....,. ..' .-.:;-;,■■»* -■ ■ ,n*i»,.-..,..,.. ...-Md Tuberculosis of Angle of Inferior Maxilla, showing Giant Cell. ■, 800. ments for the removal of carious bone. Figs. 114, 115, 116, 117 illus- trate the improved surgical engine, trephine, burs and oseotome, etc. The curette and chisel, however, answer a good purpose, if the engine is not to be obtained. The delicacy and speed with which the bone can be removed with the engine and burs places these instruments in the front rank of this kind of bone surgery. The softened or osteoporotic bone must be thoroughly removed, and the surface carefully examined, to see that healthy tissue has been SURGICAL TUBERCULOSIS. 313 Fig. 114. Thf. Surgical Engine in its Latest FoR^ 314 surgery of the face, mouth, and jaws. Fig. 11=;. Trephine and Typical Burs for Surgical Engine. Fig. ii6. Two forms of spiral osteotome, one (o) with dentate, and one (*) witli plain cutting-edges. c shows the osteotome mounted, with its button-like guard for cutting fenestra, etc., m the brain-case without injury to the subjacent membranes, a and * are twice the size of cutting-tool ; c is full size. SURGICAL TUBERCULOSIS. 315 reached; as an added precaution, the surface may be punctured at sus- picious places with a sharp-pointed steel probe, as occasionally this instrument will reveal a concealed focus of infection that can then be removed. Senn recommends that the surface be punctured with a sharp-pointed Paquelin cautery to the depth of a few lines, as this pro- cedure will destroy some of the bacilli that might remain, and also incite a plastic inflammation that would effectually resist the patho- genic action of such bacilli as were still present. Too much stress cannot be laid upon this part of the operation. The cavity is then to be dried, dusted with iodoform, packed with iodoform gauze ; the edges of the wound sutured, except at the lower angle, where space is left for the removal of the packing and for drainage. Senn fills the cavity Fig, 117. WITH Adjustable Guard for Cutting " Depth. IN-CASE TO ANS' PREDETERMINED with antiseptic, decalcified bone-chips, suturing the periosteum sepa- rately in operations upon the long bones, and claims excellent results. Such a procedure ought to be available in the treatment of certain cases of tuberculosis of the superior maxillary and malar bones having external openings, and where loss of bone-tissue would cause a serious deformity. Tubercular abscesses are treated by incision, and the removal of the tubercular membrane and granulation, and irrigation with an aqueous solution of iodin. The primary lesion must also be found and removed. Aspiration and injections of solutions of iodoform and gly- cerol are rarely practiced in connection with tubercular abscesses in the region of the face, for the very good reason that abscesses requir- ing such treatment are exceedingly rare in connection with the bones of this region. Most cases of tubercular abscess associated with the face can be treated more successfully by radical operation. 3l6 SURGERY OF THE FACE, MOUTH, AND JAWS. REVIEW. CHAPTER XXXI. At what period of life is tuberculosis of bone most common? What is the usual family history of children suffering from bone tuber- culosis? Which of the bones are most often the seat of the disease? What tissue of the bone is generally affected? In what location of the bone is the disease most often found? Is the disease primary or secondary in its origin? How does primary infection occur? Through what channels does secondary infection take place? What influence do traumatic injuries exert in producing the disease? What class of injuries seem to exert the greatest influence? Why do severe injuries seem to prevent localization of the tubercular virus and slight injuries favor localization? Are osteo-tuberculosis and pulmonary tuberculosis found associated in the same individual? Is it common for pulmonary tuberculosis and diffuse miliary tuberculosis to be traced to a preceding tubercular bone-disease? What is the general tendency of tubercular disease of the glands? What does Volkmann say upon this point? What peculiarity of osteo-tuberculosis in reference to the point of attack is almost universal? Where is this point in the long bones? Where is it in the flat and irregular bones? What reasons are given for this localization in growing bone? What is the relative frequency of tuberculosis of the bones of the head and face compared with the other bones of the body? What is the estimated frequency of the disease of the bones of the face, as figured from Billroth's table? Which bones of the cranium are most often affected? Which bones of the face are most often affected? What is tuberculosis of bone, or caries of bone? Does it differ in clinical history or appearances from the disease in other organs? What are these appearances? What only can be considered the crucial test of the disease? Are the bacilli always demonstrated with readiness? What are the difficulties encountered in demonstrating them? How are tubercular abscesses formed? What is the character of the pus found in such abscesses? Can the bacilli be demonstrated with the microscope in such pus? How then may their presence be determined? Describe the tubercular membrane which lines tubercular abscesses. What does Volkmann say of its diagnostic value? What is often the condition of the general health of patients in the early stages of tubercular bone-disease? How is the temperature affected? What would a constant low evening temperature indicate? SURGICAL TUBERCULOSIS. 317 What would progressive anemia indicate? What is the character of the pain? What would severe pain indicate? Is the pain always referred to the seat of the disease? What symptom would locate a tubercular focus? When is swelling present? Does fluctuation always indicate the presence of pus? At what stage of the disease is the color of the skin changed? What causes this dusky-red hue? What means can be used to diagnose a doubtful swelling? What diseases of the face and mouth may simulate tubercular swellings? What is the prognosis of osteo-tuberculosis? Does a spontaneous cure ever occur, and, if so, under what circumstances? Under such circumstances, is the patient liable to reinfection? What portion of the bones of the face is most frequently affected by the disease? What is the result of disease in this portion of the superior maxillary bone? What may be the result of tuberculosis in the malar bone? How may the bones of the nose become infected? What is the result of the disease in these bones? Is the disease found in the hard palate? How may it be diagnosed from syphilitic disease? How may the alveolar process become infected? What is the general treatment of osteo-tuberculosis? What is the local treatment of the disease in the bones of the face? Upon what does success largely depend? What is the danger of delaying an operation after the diagnosis is estab- lished? What instruments are considered the best for these operations? What precaution should not be neglected as a final part of the operation? How should the cavity be treated? How does Senn treat such cavities in the long bones? What is the suggestion as to its applicability in cavities in the bones of the face? How should a tubercular abscess of the face be treated? CHAPTER XXXII. SURGICAL TUBERCULOSIS (Continued). Tuberculosis of the Skin and Mucous Membrane. Tuberculosis of the Skin, or Lupus Vulgaris. — Until the pos- itive demonstration by Koch that lupus was a form of tuberculosis of the skin, there was a very wide difference of opinion among the various authorities as to the real nature and origin of the disease. The French and English authors were quite generally agreed that it was one of the manifestations of scrofula, and that it was composed of granulation- tissue. The German authorities differed very greatly as to the causa- tion of the affection. Virchow did not believe it to be a manifestation of scrofula, and classed it with the granulomata. Heuter considered it to be a fimgons inflammation, and that the specific cause was capable of producing miliary tuberculosis when introduced into the tissues. Volkmann classed it with those diseases which are characterized by the production of granulation-tissue. Baumgarten affirmed that the ab- sence of caseous material in lupus was an evidence of its non-tuber- culous character, while Friedlander stoutly maintained that lupus was a tubercular disease of the skin, identical in its histologic structure with other forms of the affection, and presenting the same characteristic miliary tubercles. At the present time there seems to be no doubt that lupus, and many other forms of skin-disease, are tubercular in their nature, and directly caused by the presence in the tissues of the Bacillus tubercu- losis. Koch not only demonstrated the presence of the bacillus in lupus nodules, but he succeeded in producing a pure culture of the microbe from lupus tissue, which in every respect resembled that produced from recognized tubercular tissue, while with the fifteenth generation of the bacillus from this culture he successfully inoculated five guinea-pigs by subcutaneous injection, producing typical tuberculosis in each of them. Before this time, however, clinical observation and the accumu- lation of anatomical proofs had demonstrated that in all probability lupoid affections were of tubercular origin, or that there was a very close relation between them and tuberculosis, but the positive proofs 318 SURGICAL TUUERCULOSIS. 319 were lacking until the discovery of Koch. The experiments of Koch have since been repeated many times by other scientists to prove the identity of the bacillus found in lupus tissue and tuberculosis, with al- most uniformly positive results. Tuberculosis of the skin is often associated with other forms of tuberculosis. Brock found 79 per cent, of the cases examined by him were complicated with other forms of tuberculosis. Rassdnitz found that 30 per cent, out of two hundred and nine cases were associated with other manifestations of tubercular disease. Bessnier reported that 21 per cent, of the cases of lupus that came under his observation eventually died of phthisis. Pontoppindan said that 50 to 75 per cent, of his patients suffering from lupus gave additional evidence of other forms of tuberculosis. Tuberculosis of the skin may be primary or secondary in its origin. All forms of primary tubercular disease of the skin are doubtless the result of inoculation with the Bacillus tuberculosis. It is some- what remarkable, however, that taking into account the frequency with which abrasions and slight wounds occur upon the exposed portions of the skin, and the many ways in which the dangers of infection with the tubercular virus are presented, the primary form of the disease does not occur with much greater frequency. It is a well-known fact that lupus occurs most frequently upon those parts of the body which are most constantly exposed to injury and infection. Lupus is found most frequently in the skin of the nose, face, eyelids, ears, and hands, locations which are not afforded protec- tion of either the hair or clothing, and which are constantly exposed to slight injuries, to the lodgment of bacilli floating in the atmosphere, and to direct inoculation with the virus from almost innumerable sources. The secondary form of the disease is usually found in pa- tients suffering from advanced tuberculosis, and is a manifestation of a general diffusion of the affection to the skin and mucous membrane, or of auto-infection in persons suffering from primary tuberculosis of the lungs. Pathology. — As primary tuberculosis of the skin is always the di- rect result of inoculation, the pathologic changes are therefore always first made manifest at the point of infection. These manifestations consist of the formation of nodules which contain all of the histologic elements of true tubercular nodules, viz: giant cells, epithelioid cells, leucocytes, and the Bacillus tuberculosis; caseous material is, however, rarely found. This is accounted for, in all probability, as suggested by Senn, from the location of the tubercular product so near to the surface of the skin, and also because the granulation-tissue soon be- comes the seat of suppuration, due to secondary infection from the pus-microbes. By the aggregation of these nodules, and the infiltration 320 SURGERY OF THE FACE, MOUTH, AND JAWS. of the surrounding cellular tissues, the lesion gradually spreads, and by the coalescence of the infiltrated portions there is established a more or less extensive area of tubercular tissue. In those cases where the break in the continuity of the tissue at the point of the infection has been restored, the cell proliferation may be so abundant as to cause a swelling resembling a papillomatous growth and covered with a scaly epidermis, the result of excessive formation and exfoliation of epidermal tissue. Whenever the underlying granu- lation-tissue becomes exposed, septic infection immediately takes place from the introduction of the pus-microbes, and the process of destruc- tion of the granulation-tissues is hastened by the action of the septic organisms and their ptomaines. Ulceration immediately takes place, the break in the continuity of the skin increases in size and rapidity, commensurate with the formation of granulation-tissue by the action of the Bacillus tuberculosis and the development of new nodules in the immediate vicinity of the ulceration. In some forms of lupus the infection remains superficial, and only the outer layers of the skin become involved; in others the destructive process strikes deeper and deeper, involving the muscles, fascia, peri- osteum, and bone, simulating very closely the clinical features of ma- lignant neoplasms. This form of the disease not infrequently attacks the face, destroying the nose, eyelids, lips, and a greater portion of the cheeks, leaving the face much like that of a skeleton. Symptoms and Diagnosis. — Tuberculosis of the skin is found most frequently in middle life; no age, however, is exempt from it. It is occasionally found in little children and persons of advanced age. The disease is usually described as a neoplastic affection of the skin, or of the contiguous mucous membrane, of highly chronic char- acter and type, manifested in the form of slowly developing small red- dish-brown or yellowish-red nodules, or centers of infiltration. These nodules, when further developed, tend to rise above the surface, and form papules or tubercles. The spread of the disease is by peripheral extension and the formation of new centers, while the older ones disap- pear by gradual resorption, or ulceration takes place, resulting in the formation of disfiguring scars. The varying degree to which the corium and the papillary layers of the skin are involved gives rise to the differences in the clinical appearances of the disease, and the terms applied to them. The ordi- narjr classification is as follows: Lupus Maculosus. Lupus Exfoliativus. Lupus Exulcerans. Lupus Serpiginosvis. Lupus Hypertrophicus. SURGICAL TUBERCULOSIS. 32 I Another classification of the various forms of tiie disease, also based upon the clinical appearances, is as follows: Non-ulcerative, or lupus non-excedcns : Ulcerative, or lupus excedens; Exfoliative, or lupus exfoliativus; Hypertrophic, or lupus hypcrtrophicus (Wagner). Lupus Maculosus is characterized by the formation in the skin of minute yellow-brown nodules or patches, usually of pin-head size, more or less transparent, and covered with epidermis. The color is changed to a lighter shade under pressure. The nodules appear to lie just beneath the surface, their outline being well defined. The epi- dermis covering the patch is usually smooth, but it is occasionally scaly or shiny. The papules commonly appear in clusters, and as they grow they approach one another, finally becoming confluent and forming ricdules of considerable size. The most characteristic feature of the lupus patch is its soft con- sistence. It is much less firm than the surrounding skin, and offers little resistance to the end of a blunt probe when pressed upon it. The normal skin will entirely resist such pressure, while the lupus patch gives way and the probe is buried in the mass. Lupus maculosus is the simple form of the affection, and is always the first stage of the dis- ease. It also appears at the periphery of old patches, and is often the first indication of a relapse in old cicatrices. This constitutes lupus non-excedens, or the non-ulcerative variety. When ulceration does not take place, the nodules may remain stationary for an indefinite period, or a spontaneous cure may take place by cicatrization. Lupus Exfoliativus is a later stage in the progress of the disease, characterized by central degeneration of the matured nodule, caseous change, and cicatrization. The skin becomes rough, scaly, and fis- sured; exfoliation takes place, leaving the skin considerably thinned or atrophied, which thus easily becomes folded or wrinkled. Lupus Exulcerans. Occasionally the lupus process terminates by a sort of subcutaneous cicatrization. Usually, however, the disease progresses to ulceration. Before ulceration takes place the surface is usually covered with thickened epidermis, v^'hich can be scraped off in white scales. L^lceration begins over the center of the nodule, and extends toward the periphery, attacking the new nodules almost as rapidly as they are formed. The ulcerative process is hastened by the secondary infection with the pus-producing micro-organisms, which enter the granulation-tissue at the border of the ulcer. Repair by cica- trization and the ulcerative process often go on at the same time in a lupus patch. Repair is more likely to occur if the tubercular process has been confined to the skin, than when it has progressed beyond this tissue. This constitutes the ulcerative variety, or hipus cxccdcns. 322 SURGERY OF THE FACE, MOUTH, AND JAWS. Lupus Serpiginosus is but another form of lupus cxcedens, in which the process of repair by cicatrization and epidermization pro- gresses in an irregular form. HeaHng may take place in the center of a lupus patch, or in a segment of the periphery, while at other points the morbid process continues, and the disease creeps on, followed by the scar, and giving rise to irregular gyrate forms. When the ulcerative process accomplishes its work of destrvtction with greatest rapidity, penetrating to muscle and bone, and destroying them, it is termed lupus vorax. Lupus Hypertrophicus is a form of the disease in which there is an exuberant formation of tissue which produces a papillary growth. These papillary growths are probably derived from the granulation- tissue which has been covered by epithelium in the process of healing, and may remain as permanent warty growths, or at other times become soft and fungous, with a tendency to bleed. When this form of the disease is located in the lower extremities, the formation of hypertro- phied tissue is sometimes so excessive as to cause a very considerable enlargement of the limbs, producing a species of elephantiasis. This latter form never remains as a permanent condition, but sooner or later, sometimes after years, the hypertrophied tissue breaks down, followed by ulceration and cicatrization. Tuberculosis of the Skin of the Face. — The first manifestations of lupus in the face are the so-called primary efflorescences found upon one or both cheeks, upon the nose, or upon the cheek and nose, in the form of a dull-colored maculation upon the skin, often unnoticed for a long time ; or it may appear in the form of a minute nodule ; or a thick- ened purplish patch, the size of the finger-nail. The disease spreads, as already described, by extension from a single patch, or by multiple lesions. The contraction of the cicatrices formed by the process of healing often results in great disfigurement of the face, in some cases causing ectropion of the eyelid or lip. The nose often becomes very much reduced in size after the ravages of the disease have subsided, the point being markedly sharpened, though occasionally, according to Hyde, the point becomes bulbous, flattened, livid, and knobbed, with a thickened septum and distorted als. The upper Hp is frequently involved when the disease is situated upon the nose, marked at first by considerable swelling, followed by fissures which are prone to bleed and the formation of crusts on the granulating surface. Considerable deformity usually follows the heal- ing of tubercular ulceration of the upper lip, the mouth being some- times reduced to a mere slit or hole in the face, with little power to open or close it. Tuberculosis of the Mucous Membrane of the Mouth. — Tubercular disease of the mucous membrane of the mouth is generally SURGICAL TUBERCULOSIS. 323 found as an extension of the afifection from the neighboring infected integument. In the great majority of cases it is secondary to tuber- culosis of the skin, proceeding from this tisstie to the mouth, extending to the mucous lining of the lip, the gum, the hard palate and the velum palati, or the pharynx, or the conjunctiva. Primary tuberculosis of the mucous membrane is comparatively of rare occurrence. When it is remembered that the oral cavity is often the seat of superficial injur- ies and pathologic changes which form excellent points for infection with the bacillus, it seems a wonder that the primary form of the dis- ease is not much more prevalent in this locality than it is. The changes which take place in the mucous membrane are the same as when the disease is located in the skin. The lupus nodules, as found in the mucous membrane, are minute white points, set in the livid red and slightly thickened membrane; they may assume the form of a papillary outgrowth or a granulating patch, which may ulcerate and cicatrize. Ulceration is an earlier and more frequent symptom in tuberculosis of the oral cavity than in other locations, on account of the constant maceration of the newly-formed abnormal tissue by the fluids of the mouth. The ulcerating patch has well-defined borders, and is usually covered by a whitish film or false membrane, produced by the death of the superficial layers of the mu- cous membrane. On removal of this pseudo-membrane the character- istic granulating surface is exposed. Caseation is seldom seen. Ul- ceration and cicatrization sometimes cause serious deformities which interfere with the proper function of the parts. The most characteristic feature of tubercular ulcer of the mucous membrane of the mouth and the tongue is the presence of minute tubercular nodules in the margins and underneath the layer of granula- tions, and if the infection has extended to some distance, in the sur- rounding mucous membrane also. (Senn.) The disease is most often seen in persons from fortv to fifty years of age, and rarely attacks the vcr\" \oung. Tuberculosis of the Tongue and Pharynx may be seen inde- pendently of the disease in the skin, and may be primary or secondary in its origin. Tubercular ulcers of the tongue are exceedingly rare. Butlin says the disease is so uncommon that at intervals it excites an entirely new interest, and is described almost as if it were a new disorder. These ulcers are most often situated upon or near the tip of the tongue, though they are found in all locations, especially upon the dorsum. Men are more prone to the disease than yvomen, and adults more than children. The ulcer (or ulcers, for there may be more than one) is at first indolent, not painful or very tender, but later, as the disease takes on a more active progression, it becomes more and more painful, ex-^ 324 SURGERY OF THE FACE, MOUTH, AND JAWS. ceedingly sensitive, and salivation becomes a marked symptom. Fig. ii8 represents a typical tubercular ulceration of the tongue. In some cases the tongue is rapidly destroyed, the lymphatic glands be- coming infected, and as the sore extends the strength of the patient fails, death resulting in a few months, or at the end of a year or two. Fig. 119 shows a tubercular nodule from the same case with giant cells and beginning caseation. Fic. 118. Round-celled infiltration Tuberculous Ulcer of the Tongue. X 50. Tubercular disease of the pharynx may extend to the tonsils and velum palati, destroying these organs, or if cicatrization takes place the posterior nares may become more or less contracted, and the exer- cise of function become greatly hindered, speech also being rendered imperfect. The larynx may also become involved from extension of the disease, and aphonia result from implication of the epiglottis and the vocal cords. SURGICAL TUBERCULOSIS. 325 Differential Diagnosis. ^In the diagnosis of lupus of the face and mucous membrane, it must be borne in mind that the clinical features of certain forms of tertiary syphilis and epithelioma closely simulate those of tuberculosis of the skin and mucous membrane, and to differ- entiate them is sometimes very difficult or well-nigh impossible. Even the microscope in the hands of an expert cannot always be relied upon as an exclusive means of diagnosis, on account of the great similarity in the histologic elements of a tubercular nodule and a gumma. Fig. iig. Early tubercle beginning caseation. Tuberculosis ok Tongue, showing Giant Cells and Caseation. ; 50. A careful examination into the history of the case is of the greatest importance when trying to differentiate between tuberculosis and syph- ilis, for even though the patient may be sure that syphilis has not been acquired, still it is possible that the disease may have been inherited; while on the other hand, although a positive history of primary and secondary syphilis may have been established, it is not improbable that the manifestations may be those of tuberculosis. When doubt exists as to the true nature of the disease, the matter may be cleared up in the course of a month or six weeks by prescrib- 326 SURGERY OF THE FACE, MOUTH, AND JAWS. ing anti-syphilitic treatment, and at the same time inoculating' several guinea-pigs or rabbits, after the method of Koch, by implanting sub- cutaneously small fragments from the diseased area, as these animals are very susceptible to tuberculosis. The doubt is removed either by the improvement manifest in the ulceration, after two or three weeks, as a result of the anti-syphilitic treatment, or by the production of tuberculosis in the inoculated ani- mals, and their death at the end of five or six weeks. If the fragments which have been implanted are from syphilitic ulcers, it will have no effect upon these animals, as they cannot be inoculated with syphilis. In dififerentiating between tuberculosis and epithelioma, the micro- scope is the only reliable means of diagnosis. A section of a tubercular nodule shows a fine, delicate reticulum, the meshes of which are occu- pied by granidation-cells ; in epithelioma there is a well-marked retic- ulum, the alveolar spaces of which are filled with embryonal epithelial cells, arranged concentrically. Blood-vessels are also abundant in epithelioma, and absent in the tubercle nodule. Glandular infection is an early manifestation in epithelioma, while in tubercular ulcerations of the mucous membrane it is a late manifes- tation or may not occur at all. Simple ulcers of the cheek and tongue sometimes occur from the mechanical irritation of a sharp or jagged tooth, resulting from a cari- ous cavity, or from masses of salivary calculus, or from a misplaced tooth. Such ulcerations are easily recognized from their location and appearance, and onl}- a careless observer would be misled. It should be borne in mind, however, that they may become the focus of infec- tion'of tuberculosis, or the starting point of a carcinomatous growth. Prognosis. — Although lupus is usually confined to the skin, it may attack deeper parts, involving the muscles and periosteum, caus- ing necrosis of the bone. Primary tuberculosis of the skin may lead to infection of the lymphatic glands nearest to the seat of the disease, and eventually to general miliary tuberculosis. Pulmonary tuberculosis often develops as a secondary complication. It occasionally happens that a lupus patch is the cause which locates the formation of a carci- noma. The tendency to local extension varies greatly. In some cases the disease may begin in early life, remain stationary for a number of years, then suddenly become very active and not confined to the skin, but attacking the deeper tissues and destroying them with the greatest rapidity, regardless of their structure. In tuberctilosis of the face, the tendency is toward rapid extension; in some cases the soft tissues and the superficial bones may be completely destroyed in a few months. On the other hand, the process of repair by cicatrization follows closely upon the destruction of tissue, and extensive scars are formed, causing frightful deformity. SURGICAL TUBERCULOSIS. 327 The prognosis, so far as the Hfe of the patient is concerned, is fav- orable so long as the disease remains local, or does not progress more rapidly than the process of repair. Regional infection of the lym- phatic glands is always considered as a menace to life, as sooner or later important internal organs are affected, or miliary tuberculosis be- comes general. A spontaneous cure is sometimes effected. The dis- ease, however, is prone to recurrence in the scar tissue. The prognosis of tubercular ulceration of the mucous membrane of the mouth is usually favorable, except when located in the tongue. When associated with generalized tuberculosis, or cachexia, as occas- ionally happens, the prognosis is exceedingly unfavorable. The de- struction of the membrane is sometimes very extensive, and the result- ing cicatrix, by its contraction and adhesions, causes unsightly de- formity, often greatly interfering with the function of the parts. The prognosis of tubercular ulcer of the tongue is almost as bad as in carcinoma. The disease is not only fatal, but the lease of life is usually short, the end coming in a few months, or in a year or two at the longest. The pain and distress which accompany the downward course of the disease is very great, while the patient is considered as fortunate if the end is hastened by the presence of a rapidly-progressive tuberculosis of some important internal organ, which produces a fatal termination before the ulcer of the tongue becomes large and painful. Occasionally tubercular ulcers of the tongue heal, but the cure is usu- ally only a temporary affair, for sooner or later the disease returns, the second outbreak being more rapid in its course, and all efforts for its cure are unavailing. (Butlin.) Treatment. — The internal treatment of tubercular disease of the skin and the mucous membrane should be governed by the indications of the patient. There is no known remedy that has any specific action in curing the disease, or, according to Hyde, that is capable of reliev- ing the victim of his local ailment. Recent authors think the only remedy that deserves any confidence is arsenic, in the form of Fowler's solution. It is administered in doses of from three to ten drops after meals, diluted with water, beginning with the smallest dose and grad- ually increasing until the maxinumi dose is reached or the physiologic effect is produced, and then gradually diminishing. To be of any real vahie its use must be continued for several weeks or months. Cod-liver oil, the tincture of chlorid of iron, the bitter tonics, com- bined with nutritious diet, out-door exercise and sea-bathing, are the most useful agents in sustaining the general health, assisting nature to limit the spread of the disease and favor the process of repair. The local treatment consists of the removal of the diseased tissue by surgical operation, under anesthetics; to be efficient it must be thorough; half-wav measures are of no more real value here than they 328 SURGERY OF THE FACE, MOUTH, AND JAWS. would be in the treatment of malignant neoplasms, for the disease is almost sure to recur unless every particle of infected tissue is removed. The use of caustics is generally of no real value, often positively harmful. Since the nature of the disease has been recognized, antiseptic agents have been recommended for local treatment. White uses the bichlorid of mercury, one to two grains to an ounce of water, applied for half an hour morning and evening on compresses kept wet with this solution, or an ointment made from the same drug, two grains to the ounce, applied continuously, and changed morning and evening. Care must be taken that saHvation is not produced by absorption of the drug. He also obtained satisfactory results by the application of a 2 to 4 per cent, solution of salicylic acid in castor oil. Iodoform in the form of the powder, ointment, or emulsion in glycerol is recom- mended as one of the very best antiseptics in all forms of tubercular disease. Balsam of Peru is also of benefit as a local application. Dr. Thomas S. K. Morton, of Philadelphia, recommends ace- tanilid as an antiseptic dressing in all surgical wounds, tuberculous ulcerations, and bone-disease, either in substance or as gauze, or oint- ment (i in 8), or dissolved in alcohol or oil (as an injection). A 10 per cent, solution in water seems to answer every purpose in preventing suppuration in all surgical cases, while it seems to act better than iodo- form in the treatment of tuberculous lesions. Care must be exercised in the use of the drug in substance to prevent toxic symptoms. Antiseptic agents, however, can never become efficient means of treatment in this affection, for the reason that they cannot be brought into direct contact — except at the surface and for a little distance be- neath — with the bacilli and those parts in an active state of disease. In those cases in which a radical operation is declined by the patient or friends, the above treatment is the next best means at the disposal of the surgeon. Excision is the most effectual form of radical treatment, but un- fortunately it cannot be performed in all cases. This operation is not admissible when the disease is upon the nose or some other prominent part of the face where the resultant deformity would be nearl)' as unwelcome to the sufferer as the disease, nor where the disease is very extensive. When excision is practiced, the lines of incision should be made at some distance from the margins of the visible diseased area, in order that all infected tissue may be included; while great care should be ex- ercised in removing the deeper portions of the infiltration, as this may send out projections at various points, which must be extirpated in order to insure non-recurrence. If it becomes necessary to remove SURGICAL TUBERCULOStS. 329 extensive portions of the skin, the gap may be filled by the Thiersch method of skin-grafting. Another method of radical operation is by curetting. This opera- tion consists of scraping out the diseased tissue by means of sharp spoons or curettes. Lupus tissue is much softer than the healthy skin, consequently the curette easily penetrates the former, while the latter offers sufficient resistance to guide the operator in removing the diseased tissue. Bessnier recommends the use of the galvano-cautery for removing the diseased tissue, and he has devised special cautery points for this purpose. The writer believes the most effectual plan of treatment is a com- bination of the last two methods, the bulk of the diseased tissue being first removed by the curette and then followed by the galvano-cautery. The storage battery makes it possible for every surgeon to use Bess- nier's cautery point and knives. No more successful method can be used to follow up and remove the more minute points of the disease which have been left behind by the other operations of excision and cviretting. Antiseptic after-treatment is very desirable, and the patient should be kept imder observation for some time after the healing of the wound. The site of the operation should be protected from injury for several months, as a precaution against the pathogenic action of re- maining latent bacilli or reinfection from the outside. The treatment of the disease located in the mucous membrane of the mouth should be upon the same general principles as when located in the integument. The curette and galvano-cautery are most applic- able for radical treatment. Excision, if practiced early, is the most effectual treatment in tubercular ulceration of the tongue. This may be accomplished by removing a M'edge-shaped piece with the knife, and stitching the sur- face together, or it may be removed with the ecraseur or the galvano- cautery. Methods of operating will be found described in the chapter which deals with carcinoma of the tongue. Recurrence, however, is the rule after operations for this disease when located in the tongue. 330 SURGERY OF THE FACE, MOUTH, AND JAWS. REVIEW. CHAPTER XXXII. What did Koch demonstrate in reference to the nature of kipus vulgaris? What were the previous opinions as to its nature? What is the cause of tuberculosis of the skin? How did Koch demonstrate this? Is lupus associated with other forms of tubercular disease? How does the disease originate? How does primary lupus originate? How does secondary lupus originate? Does lupus differ in its histologic pathology from other forms of tuber- culosis? Does caseation take place? Why is caseation so seldom found? How does the disease spread? How are the warty growths of lupus formed? What occurs when the granulation-tissue becomes exposed? What governs the rapidity of the extension in the ulcerative process? What characterizes the more severe or malignant type of lupus? At what period of life is lupus most common? Does it ever occur at the opposite extremes of age? What are the symptoms and diagnostic features of the disease? What gives rise to the various terms applied to lupus? What is the ordinary classification of the disease? Describe lupus maculosus. What is the most characteristic feature of lupus? How may this softness be demonstrated? Is this form always the first stage of the disease? What does it indicate when found in old cicatrices? What other name is applied to this form of the disease? Describe lupus exfoliativus. Describe lupus exulcerans. What form of secondary infection hastens the ulcerative process? What two processes sometimes go on together in the same lupus patch? Under what conditions is repair most likely to occur? What other name is applied to this form of the disease? Describe lupus serpiginosus. What term is applied to the disease when the ulceration is rapid and pene- trates to the deeper tissues? Describe lupus hypertrophicus. From what are the papillary growths derived? What becomes of these growths? How is the disease manifested in the lower extremities? What are the manifestations of lupus of the face? What is the result of lupus of the nose? What are the manifestations of the disease in the upper lip? What is sometimes the result of the disease in the lip? What is the usual cause of tuberculosis of the mucous membrane of the mouth ? SURGICAL TUBERCULOSIS. 33I Is the primary form of the disease common or rare? Is there any difference in the patliology of the disease as found in the mucous membrane and the skin? What are the diagnostic signs of the disease in the mouth? Is ulceration an early or a late symptom? What is the character of the borders of the ulcerating patch? Is caseation a feature in this location? What frequently results from the formation of large cicatrices? What is the most characteristic feature of lupus of this membrane? At what age is the disease most often seen? Is the disease ever found in the tongue and pharynx independently of the disease in the skin? Is the disease in the tongue common? Where is it usually located? In which sex does it most often occur? Does it occur most often in adults or children? Describe the course of the disease in the tongue. What is the result of the disease in the pharynx? What diseases simulate lupus in the skin and mucous membrane? Is there any difficulty in differentiating them? What are the difficulties? How may the diagnosis be established between lupus and syphilis? How may the diagnosis be established between lupus and epithelioma? What are the histologic differences? How are the lymphatics affected in each? What other form of ulceration may be mistaken for these diseases by a careless observer? What is the prognosis in lupus of the skin? What is the tendency in lupus of the face? What is the result when repair takes place? What is the prognosis in tubercular disease of the mucous membrane? Under what conditions would it be unfavorable? What is the prognosis when the disease is located in the tongue? Does a permanent cure ever take place? What is the internal treatment for the disease? What drugs, if any, are valuable in this disease? What are the methods of local treatment? Detail the antiseptic treatment. What are the methods of radical treatment? Which method is the most effectual? Where is this method inadmissible? Describe the method of excision. How may the gap be filled? Describe the method of curetting. What other means may be used to accomplish the same purpose? What is the writer's recommendation? What should be the after-treatment? Which method is most applicable in lupus of the mucous membrane? Which method will give the best results in treating the disease in the tongue? What other methods can be utilized? CHAPTER XXXIII. DISEASES OF THE MAXILLARY SINUS. The Maxillary Sinus, or Atitnmi of Highnwre, is a cavity in the body of the superior maxillary bone, somewhat pyramidal in form, hav- ing its base at the nasal fossa, and its apex directed toward the maxil- FlG. 120. Left Superior Maxillary Bone, exhibiting the Communications between Antrum and Nasal Cavity, (.^fter Zuckerkandl.) O, orbital cavity; H, maxillary cavity of antrum of Highmore ; M, slit-like opening osteum max- illare ; A, accessory opening between antrum and nasal cavity. lary tuberosity. (Fig. 120.) It communicates with the nasal cavity by an irregular opening in the external wall of the middle meatus. Through this opening the mucous membrane of the nasal cavity, the Schneiderian membrane, passes to line the sinus. 332 DISEASES OF THE MAXILLARY SINUS. 333 The niaxillan- sinus has five walls; an internal, which is the lateral wall of the nasal cavity and forms the base of the pyramid (Fig. 121); an antero-external, which is the antero-external portion of the body of the superior maxillary bone; a superior, which is the floor of the orbit; a posterior, which is that portion of the superior maxillary bone that articulates with the pterygoid process of the sphenoid bone; and an inferior, which is that part of the superior maxillary bone from which arises the alveolar process. The thinnest and most inferior, or de- pendent portion of this wall, is opposite the alveoli of the second molar tooth. The floor of the antrum has generally an uneven surface, the eminences corresponding to the roots of the teeth. Occasionally the roots of the first and second molars penetrate the floor of the sinus. Fig. 121. I.N'I-'ERIOR SuRI Vt-E I THE RiGHT SuiERlOP P, palate process; S, anterior nasal spine M, lower meatus ot nasal ( \ antrum of Highmore Bone. L, lachryn Bony septi are frequently found crossing the floor from side to side. The septi rarely extend higher than one-fourth to one-third of the dis- tance from the floor to the roof of the sinus. The sinus has a capacity of from two drachms to one ounce, or even more. The other accessory cavities which open into the nasal passages are the frontal and sphenoidal sinuses. The frontal sinuses are two irregular cavities situated between the plates of the frontal bone, on either side of the median line. They are not present in childhood, but are fully developed in adult life. They communicate with the nares b}' a rounded canal, which opens into the middle meatus, and is called the infundibulum. Cryer has shown, in a paper read before the American Dental Association in 1895, illustrated by the stereopticon and pub- lished in the Dental Cosmos for J^inuary, i8q6, that the infundibulum 334 SURGERY OF THE FACE, MOUTH, AND JAWS. often discharges directly into the antrum, and in others so near to the osteum maxillare that it might discharge into it. This was a new dis- covery, and goes far toward an explanation of the difficulties often encountered in the treatment of antral inflammation. In describing this newly-discovered relationship and in explanation of Figs. 122 and 123, he says this "is a sagittal section made near the inner wall of the orbit. The frontal sinus is seen at the top, and below this is the inner wall of the orbit, os planum of the ethmoid, including the edge of the Fig. 122. Probe passing frontal sinus. . ,'( Probe pass- 3L- ^ — ' ing into mid- dle meatus. Probe passing frontal sinus. inner portion of the floor, below which is the internal wall of the max- illary sinus. . . . To locate the opening and the direction in which the excess of fluid would pass from the sinus, a wire has been passed backward into the hiatus semilunaris. A perpendicular probe passes through the upper portion of the opening of the sinus, which in this case is partly in its roof or at the angle of the internal wall and the roof; as the straight probe passes out of the antrum, it passes through the infundibulum into the frontal sinus, showing that fluids could pass DISEASES OF THE MAXILLARY SINUS. 335 directly downward from the frontal into the maxillary sinus." These specimens also show "where the anterior ethmoidal cells open just at the maxillary sinus. If the hiatus semilunaris should be closed by pressure of the septum or inflammation of the mucous membrane, the fluids from the frontal and ethmoidal cells would pass into the antrum." Fillebrown, in a paper read before the American Dental Association in 1896, and published in the Dental Cosmos for November, 1896, states Fig. 123. it as his opinion that in certain obstinate chronic cases of empyema of the antrum, the frontal sinuses are also affected, and that the inflamma- tory secretions from these sinuses drain into the antra, and thus keep up the inflammator)^ conditions of the latter sinuses. But inasmuch as such a supposition was contrary to the accepted opinion upon the subject, and also not in accord with the generally accepted teaching as to the anatomical relations of the parts, he instituted a line of investi- gation in order to demonstrate the correctness or the possible error 336 SURGERY OF THE FACE, MOUTH, AND JAWS. as to the relations of the infundibuhim and the point at which it discharged its secretion. The text-books on anatomy state that the infundibulum terminates in the middle meatus of the nose, but Fille- brown's investigations do not bear out the correctness of this state- ment, for he has found in eight subjects, taken at random, that in every one the frontal sinuses communicated directl}' with the antra, thus cor- roborating the investigations of Cryer. He says, "The infundibulum, instead of terminating directly in the middle meatus, continues as a Fig. 124. (After Fillebrown.) half-tube, this half-tube terminating directly in the foramen of the maxillary sinus. In seven of the specimens there was a fold of mucous membrane which served as a continuation of the unciform process and reached upward, covering the foramen and forming a pocket which ef- fectually prevented any secretion from the frontal sinus getting into the meatus until the antrum and pocket were full to overflowing." Dr. Fillebrown further thinks that this pocket cannot be an anom- aly, as thought by some other observers, as it was found in seven out DISEASES OF THE MAXILLARY SINUS. 337 of eight subjects, but that its absence might be considered anomalous, rather than the usual type. Figs. 124, 125, 126 illustrate the points made by the author of the paper. The sphenoidal sinuses are two cavities hollowed out in the body of the sphenoid bone, and are separated from each other upon the median line by a thin lamella of bone. These sinuses are also lined with mucous membrane. Fig. i2j. Frontal sinus (After Fillebrown.) Diseases of the maxillary sinus are quite common, much more so than is generally supposed. These diseases are more common among the lower classes of society, especially those who give no attention to the care of their teeth. Abundant proof of this statement can be found in any of the surgical clinics in the free dispensaries and hospitals of our large cities. Climatic influences are important factors also in the production of certain forms of antral disease. Mucous engorgements, and empyema, are much more prevalent in damp and changeable climates, where catarrhal conditions abound, than in dry or equable climates. 23 33^ SURGERY OF THE FACE, MOUTH, AND JAWS. The diseased conditions most commonly found affecting tlie max- illary sinus are : 1st. .Suppurative inflammation, or purulent empyema. 2d. Mucous engorgements. 3d. Syphilitic ulceration. .4th. Necrosis of the bony walls. 5th. Tumors. Fig. 126. Superior turbinate Pocket Middle turbinate Inferior turbinate Suppurative Inflammation of the Maxillary Sinus. — Suppura- tive inflammation of the antnnn is the most common of all diseases affecting this sinus. It is not an idiopathic affection. It may be acute, subacute, or chronic. In the acute form there is rarely any difficulty in making a correct diagnosis, but in the chronic very great difficulty is sometimes encountered, owing to the fact that the symp- toms are rarely well marked, and so closely simulate chronic nasal catarrh as to be easily mistaken for that affection. The disease may DISEASES OF THE MAXILLARY SINUS. 339 be unilateral or bilateral. It is extremely rare that both antra are found affected at the same time. Two cases only of bilateral disease have ever come under the personal observation of the writer. The first was a German woman about forty years of age, who presented herself at the clinic of the Post-Graduate Medical School of Chicago. Both antra were engorged with purulent secretions, the face much swollen in the infraorbital region, the left somewhat more than the right; parchment-like crepitation was present over both antra, and bulging of the palate process upon both sides. There was consider- able protrusion of the left eye, but this condition was not so marked in the right; she complained of impaired vision. The superior teeth were all decayed to the gums. This case was due to the infection of the antra with pus from several alveolar abscesses upon both sides of the jaw. The second was a recent case, in the person of a professional friend, in which the disease followed an attack of la grippe, producing a mucous engorgement of both antra, and loss of the voice as a compli- cation. This at least was the opinion of the patient, and it proved to be correct, for immediately after draining the antra the laryngeal symp- toms began to improve. This case made a quick recovery. Etiology. — The causes of suppurative inflammation of the maxil- lary sinus generally arise from one of the following local conditions : Diseases of the teeth, Presence of foreign bodies in the sinus, Traumatic injuries, Catarrhal affections. The diseases of the teeth which may give rise to suppurative in- flammation of the antrum are often of a more or less obscure nature, frequently recjuiring considerable skill in special diagnosis to arrive at a correct solution of the difficulties presented in certain cases. It is therefore no wonder that the general practitioner of medicine or of dentistry should sometimes fail to make a correct diagnosis. The lesions of the teeth wdiich may be classed as active causes in the production of suppurative inflammation of this sinus are, — (a) Devitalized pulps. (b) Alveolar abscesses. (c) Malposed teeth. Devitalized Pulps.— A devitalized pulp in the root of a tooth which penetrates the floor of the antrum may give rise to a septic inflamma- tion of the lining membrane of this cavity from the escape of the lique- fied and putrescent pulp-tissue and mephitic gases, w'ithout giving the least evidence of the real cause of the trouble other than a slight discol- oration of the tooth. Cases of this character are b\ no means uncommon, while the 340 SURGERY OF THE FACE, MOUTH, AND JAWS. obscurity of the cause of the difficulty makes it doubly interesting from the diagnostic point of view. Cases of this obscure nature have fre- quently come under the observation of the writer, which had been ex- amined by some of the very best general practitioners, without finding the cause. The difficulty in the diagnosis is greatly augmented if there are several devitalized teeth and roots in the affected side of the jaw. The location of the offending tooth then becomes a matter of conjecture, and there is no certainty of making a cure except by the ex- traction of all teeth which have lost their vitality, that may be associ- ated with the diseased antrum. Sometimes the offending tooth will be of such good color as to appear to the eye like a living tooth, and thereby be overlooked. There are three methods of diagnosing pulpless or devitalized teeth; one is to reduce the temperature by the application of a piece of ice. If the tooth be vital, the great change in temperature will cause pain; or the temperature may be reduced by throwing upon the suspected tooth a spray of ether. A second is to illuminate the mouth with the electric lamp, the patient being seated in a dark room. The living teeth will transmit the light very readily, the devitalized teeth will not, the differ- ence in the translucency being very marked. A third is to apply the Faradic current. The devitalized teeth will give no response, while the living teeth will be very sensitive to the shock. This latter method has been used by the writer for many years, and experience teaches that it is the most reliable, as he has never failed to make a correct diagnosis by this method. Alveolar Abscesses. — Devitalized pulps, under ordinary circum- stances, if not interfered with surgically, usually result, sooner or later, in the development of alveolar abscesses. A devitalized pulp in the roots of a superior bicuspid or molar, which results in the formation of an alveolar abscess, may on account of the thinness of the floor of the antrum at these locations point into the sinus, and thus establish a suppurative inflammation. An alveolar abscess which discharges into the antrum of Highmore is the most common factor in the production of suppurative conditions of this sinus. The association between the alveolar abscess and the inflammatory conditions of the sinus is sometimes quite obscure. The patient will frequently give a history of an abscessed tooth which was troublesome for a week or ten days, and then the symptoms subsided. Later, whenever a cold is taken, the tooth is a little tender. Some- times there is a bad-smelling discharge from the nose as the only symp- tom. Another case will present all of the characteristic symptoms of the disease, and the offending tooth will be readily recognized. Devitalized pulps and alveolar abscesses cause suppurative inflam- mation of the antrum by septic infection, and often produce marked DISEASES OF THE MAXILLARY SINUS. 341 symptoms during- the acute stage of general septic intoxication. When the latter condition is present, it calls for speedy and heroic treatment. Malposed Teeth. ^Malposed teeth are often found in locations where it is impossiljle for them to take their normal position in the Fig. 127. ■\N 45 Years of Age. Fig. 128. Positions occupied B^■ the Cuspid Teeth in the Jaw. alveolar arch; in fact, they are found in almost every conceivable posi- tion, and with every line of inclination. Occasionally they are found Iving near the floor of the antrum, in a longitudinal direction, or even 342 SURGERY OF THE FACE, MOUTH, AND JAWS. with an upward inclination. Fig. 127 is from a cast showing the mal- position of the superior cuspids, which were lying close to the floor of the antrum. Fig. 128 indicates the relative position which they occu- pied to each other. More rarely they have been found completely inverted. Under these conditions a suppurative inflammation may be established as a direct catise of the irritation produced by the eiifort on the part of nature to complete the development of the tooth, and force it from its bony crypt. As the pus increases in quantity, the surrounding bony walls grow thinner and eventually give way upon the side offering the least resistance. When this side of least resist- ance happens to be the floor of the antrum, the pus is discharged into this sinus, establishing an inflammatory condition of its lining mucous membrane, which may go on indefinitely if not relieved by surgical treatment. A remarkable case of this character, occurring in the family of a professional acquaintance, and coming under the knowledge of the writer, is of interest in this direction. Mrs. G., mother of the doctor, had for sixteen years been troubled with an offensive discharge from the left nostril. Prior to this she had suffered intensely from pain and swelling in the region of the left antrum, which lasted for several weeks, and then subsided. This condition was accompanied by a pro- fuse discharge of offensive secretions from the left nostril. Later the swelling disappeared, but the discharge never wholly ceased. Six years after the first attack, the face again became very painful and much swollen, this time extending farther backward toward the ear, finally developing what was thought to be abscess of the middle ear. Large quantities of pus were discharged from the ear, and at one time it was feared that the suppurative process would extend to the menin- ges of the brain. After several weeks of intense suffering the symp- toms again subsided, and finally the discharge entirely ceased from the ear. After this, however, the discharge from the hose seemed to be increased, and the symptoms were always aggravated by taking cold. The teeth of the left side of the upper jaw had all been extracted as a possible cause of the trouble, except the third molar, which had never erupted. This procedure, however, produced no abatement of the symptoms. Later, the teeth of the opposite side were removed for the purpose of inserting a complete upper artificial denture. About ten years after the last-mentioned attack, while leaning over a washbowl, brushing her teeth, she suddenly noticed that the left nostril was plugged up with some movable body. On throwing the head back, in an attempt to dislodge it, the mass fell into the fauces, and was ejected from the mouth into the bowl. Upon examination, it proved to be a well-developed left superior third molar, more ■ or less covered with hard concretions of a dark brown color. The discharge from the nose DISEASICS OF TUli M A \ H.I.A in' SINUS. 343 from this time on gradually grew less, and finall\'. after a few months, ceased altogether. The probable explanation of the peciUiar features of this case are, briefly: First, the third molar was developed in an inverted position, and very near to the floor of the antrimi; second, suppurative inflam- mation was established in the crypt of the tooth-germ from irritation induced by its development in an abnormal position; third, the pus- cavity ruptured into the antrum; fourth, the abscess which ruptured into the middle ear may have been caused by the tooth, though there is some doubt as to this, as the anatomy of the parts would not favor such a supposition. The tooth probably became dislodged at this time, and escaped into the antrum; fifth, at a later period it must have be- come lodged against the nasal wall of the antrum, causing ulceration, which finally permitted it to pass into the nasal cavity, and thus be expelled. Foreign Bodies. — Foreign bodies of various materials are occas- ionall}' met A\ith in the antrum as a cause of disease. Those most com- monly found are the roots of teeth which have slipped from the forceps and escaped into the sinus through an enlarged alveolus in attempting to extract them; malposed teeth which have erupted into it, or have found entrance through pathologic conditions; fragments of bone or of teeth which have been forced into it by some crushing injury of the walls of the antrum ; portions of lead or other metal which have lodged there as a result of gunshot injuries; and particles of food which have found entrance through some artificial opening that has been made for the treatment of a pre-existing diseased condition. The presence of any foreign substance is usually productive of inflammatory conditions of the lining mucous membrane, resulting in subacute or chronic inflammation, with purulent discharge, or of en- gorgement and protrusion of the walls, with possibly graver conse- quences. When there is no positive history of the entrance of such foreign bodies, the diagnosis sometimes becomes exceedingly difficult, and can only be reached by a critical examination of every feature and symptom of the disease, one by one excluding those causes which do not give a marked history, then from the remaining possible etiologic factors, by a still closer analysis and exclusion, arrive at a correct diag- nosis. The diagnosis being assured, operative measures are necessary. These measures comprehend the making of an opening into the an- trum, the search for the foreign liody, and its removal. The selection of the point at which to open the antrum should be governed by the surrounding conditions. The unnecessary sacrifice of sound teeth in order to gain eas\- access to it does not commend 344 SURGERY OF THE FACE, MOUTH, AND JAWS. itself to a wise conservatism. In the extraction of teeth for this pur- pose those should be selected which from their condition and location are of the least value to the individual, provided only that they are in close relation to the floor of the antrum. If a bicuspid or a molar has already been lost, it is preferable to enter the antrum from this point rather than sacrifice remaining sound teeth. Traumatic Injuries.- — Traumatic injuries involving the maxillary sinus are of rare occurrence, and are the result, generally, of gunshot wounds or crushing injuries of the face, causing fracture and comminu- tion of the superior maxillary bones. Cases of this character almost invariably terminate in suppurative inflammation, — at least this has been the observation of the writer. This is explained by the fact. that such injuries always produce compound fractures of the bone, and when associated with the oral cavity are always infected from the secre- tions and alimentary debris, consequently septic inflammation is prone to follow, as is the case with compound fractures of the lower jaw which communicate with the mouth. Disease of this character is much more amenable to treatment, as a rule, than are those conditions which result from disease of the teeth, for the reason that in the first the inflammation is generally of acute type, while in the latter it is usually subacute or chronic ; the character of the infection may also be a modifying factor. Catarrhal Affections. —Catarrhal affections of the nasal mucous membrane often result in the extension of these conditions to the frontal, sphenoidal, and maxillary sinuses. The mucous membrane lining the accessory cavities is a reflection of the membrane which lines the nasal passages; consequently the inflammatory conditions which affect the mucous tissue of these passages are quite likely to extend to the accessory cavities which open into them through the continuity and functional identity of their lining membrane. Mucous Engorgements.— Among the most common of the catar- rhal inflammations of the nasal passages which may extend to the ac- cessory sinuses and produce mucous engorgements are acute and chronic coryza, and la grippe or influenza. Mucous engorgements, in the opinion of the writer, are much more likely to follow acute catarrhal inflammations than the chronic form. Acute coryza, or cold in the head, is usually the result of exposure to cold, though it is occasionally due to the irritating effects of acrid vapors, or other irritating substances. It also occurs at the com- mencement of certain of the eruptive fevers, as measles, scarlet fever, etc., and in rare cases, the breathing of the vapor of iodin, or of particles of ipecacuanha in those possessing peculiar idiosyncrasies will bring on an attack. DISEASES OF THE MAXILLARY SINUS. 345 The onset of an attack of acute con'za is ushered in by varying degrees of chill, from a slight chilly sensation to a pronounced rigor, a feeling of lassitude and general malaise, followed by a slight increase in body temperature, with myalgia and loss of appetite. The mucous membrane of the nasal passages becomes congested, accompanied by a sense of burning and prickling, with a feeling of dryness and heat. This may last for a few hours, or even a couple of days, when a watery, acrid discharge sets in, gradually changing in the course of a few days to a thick yellow mucus, more or less copious in amount, and finally to a free discharge of a purulent character. The duration of the attack may be from three or four days to two or three weeks. These symptoms are the result first of congestion of the mucous membrane and the arrest of the secretions producing the characteristic dryness. This is followed by a free transudation of the liquor san- guinis from the engorged blood-vessels, causing swelling of the mem- brane, and supplying the main portion of the earliest secretion, which is of a serous character. Later, the glandular structures are stim- ulated to an abnormal activity, and a profuse discharge is established, consisting of mucus, epithelial cells, and leucocytes, with a slight ad- mixture of red blood-corpuscles. As the disease progresses, the em- bryonic cells increase in numbers, and the secretion assumes a purulent character. When the nasal mucous membrane is alone affected, the discomfort is referable to the nose only, and consists of an increased secretion, sense of fullness, or complete occlusion, due to swelling of the membrane, and repeated and distressing attacks of sneezing. If the disease extends to the frontal sinuses there is often, as a marked symptom, a severe frontal headache; when the antrum of Highmore is involved, there is usually a more or less severe neuralgia, referred to the infraorbital or malar region. If the inflammatory symptoms are severe, causing considerable swelling and thickening of the mucous membrane, it is likely to result in the closure of the openings into the nasal passages of the accessory sinuses, and consequent retention of the secretions, followed by the symptoms described under the head of suppurative inflammation of the antrum. La grippe is frequently manifested in an acute inflammation of the mucous membrane of the nasal passages, which often extends to the accessory sinuses, leading to mucous engorgement and other more serious involvement, especially of the antrum of Highmore. It was the experience of the writer in the last epidemic of la grippe in Chicago, during the winter of 1891-92, to treat a larger proportion of cases of engorgement of the maxillary sinuses as a direct result of attacks of this disease which were principally confined to the upper air- passages, than from any other or all other causes combined. The prognosis in these cases, as in those arising from acute 346 SURGERY OF THE FACE, MOUTH, AND JAWS. coryza, is much better than when the cause is some chronic inflamma- tory condition of the mucous membrane. Chronic coryza is the result of repeated attacks of the acute dis- ease, or it ma)' occasionally be of a chronic type from the beginning. The most prominent symptom is an increased secretion of mucus, or of muco-pus, which is discharged through the nose, or through the pharynx into the mouth. The discharge is semi-fluid, having some- what of a purulent character, on account of the copious admixture of embryonic cells and of epithelial scales with the mucus. There is no marked thickening of the mucous membrane, and its surface is at all times soft and moist. Its color is abnormal, showing a reddened, con- gested appearance, sometimes turgid or purplish. The disease is aggravated by changes in the weather, and is more prominent in the chilly spring and autumn days. Such conditions, when affecting the antrum, rareh' cause stenosis of the nasal opening, consequently the discharges escape from time to time into the nose, when the body assvmies a favorable position for the drainage of the cavity. The secretions, as a rule, however, are not discharged with sufficient free- dom to prevent their decomposition and consequent fetid odor, though sufficiently so to prevent the sense of fullness or the expansion of the antrum, so common in those cases having retained secretions. REVIEW. CHAPTER XXXIII. What is the location of the maxillary sinus? What is its shape? In what direction does the apex point? Has it any communication with the nasal passages, and where? With what is the antrum lined? How many walls has the antrum? Give the name and location of these walls. Where is the thinnest, most dependent point of the antrum? What is the character of the floor of the antrum? What is the capacity of the antrum? Name the accessory cavities. By what canal may the frontal sinuses discharge into the antrum? What do Cryer's investigations prove as to the anatomy of the parts? Do Fillebrown's investigations corroborate these discoveries? Are diseases of the antrum common or rare? In what class of society are they most prevalent? What are some of the conditions which predispose to antral disease? What are the most common diseased conditions affecting it? DISEASES OF THE .Nf.WlLLARY SINUS. 347 Which of these is most l'rec|iieiitly met witli? What are the causes of suppurative iiiHammation of t)iis sinus? Name the lesions of the teeth that may prothice this affection. What are the forms of inflammation? How may a dead pulp cause it? What are the methods employed for testing the vitality of suspected teeth? How may an alveolar abscess cause suppuration of the antrum? Does septic intoxication ever accompany acute suppurative inflammation? How may a malposed tooth produce the disease? How did the third molar in the case described produce the disease? Name the foreign bodies that are sometimes found in the antrum. How do such substances produce suppurative inflammation? What is the character of the inflammation under these circumstances? Are such conditions easily diagnosed? How may the diagnosis be made sure? What are the traumatic injuries that may result in this disease? What is the usual result of such injuries when associated with the oral cavity? Why is suppuration more likely to supervene under such circumstances? How may catarrhal affections of the nasal mucous membrane produce en- gorgement of the antrum of Highmore? What catarrhal afifections are the most common causes? Are acute or chronic inflammations of the lining membrane more likely to cause the disease? Describe the symptoms of acute coryza. Describe the pathologic changes which take place in the mucous mem- brane. What is the characteristic symptom of extension of the disease to the frontal sinus? What symptom marks its extension to the ma.xillary sinus? What is the result of severe inflammation of the lining membrane of the accessory cavities? May this swelling, etc., cause stenosis of the nasal opening, and what would be the result? How may la grippe cause engorgement of the antrum? Is it a prolific cause of this condition during epidemics? What is the prognosis in those cases caused by acute inflammations? What are the symptoms of chronic coryza? Does the disease cause stenosis of the maxillary sinuses? How and when are the secretions discharged? Does decomposition occur, and is fetor present? Why are these conditions present? CHAPTER XXXIV. DISEASES OF THE MAXILLARY SINUS (Continued). Suppuration of the Antrum of Highmore. Symptoms. — The symptoms of suppuration of the antrum are pain, which is at first dull and deep-seated, later becoming more in- tense, shooting over the face and forehead, sometimes including the ear. Occasionally the pain is very acute, and of a sharp, stabbing character. The cheek becomes swollen and tender; the walls of the antrum are thinned, and later give forth, under pressure, a crackling sound, like that of crushing an egg-shell, or of crumpling parchment. Frequently there is protrusion of the eyeball, sometimes accompanied by amaurosis. This feature is due to the thinning of the floor of the orbit, or roof of the antrum, and protrusion into the orbital cavity, which forces the eyeball outward, and causes paralysis of the optic nerve from pressure upon it. In acute cases, the formation of pus is ushered in with a rigor, followed by elevation of temperature and gen- eral systemic disturbance. In the subacute and chronic forms, the constitutional symptoms may be entirely absent. Generally there is an offensive, purulent discharge from the nostril of the afifected side; this symptom, however, may not be present, on account of the closure of the normal opening into the nasal passages, the osteum maxillare, from induration of the lining mucous membrane. In the latter condi- tion the protrusion of the antral walls is usually much greater, and the suffering induced by the pressure of the pent-up inflammatory pro- ducts is often very severe. Sooner or later the walls of the antrum are absorbed, the soft tissues are penetrated, and the fluid escapes. The location at which the rupture of the wall takes place is generally that point which offers the least resistance. This varies greatly in different individuals. The most common locations are the nasal wall, the palate process, and the infraorbital plate, or roof of the antrum. Occasion- ally the buccal wall will give way, or the fluid may follow the root of a tooth which penetrates the floor of the antrum, and discharges into the mouth; more rarely it may burrow backward, after having penetrated the floor of the orbit, and enter the brain through the sphenoidal fissure or the optic foramen. Rupture of the walls of the antrum usually 348 DISEASES OF THE MAXILLARY SINUS. 349 causes considerable ulceration and necrosis, which may involve the en- tire maxillary bone. If the discharges enter the cranial cavity, epilep- tiform convulsions are likely to be induced, with other brain-symptoms, closely followed by a fatal termination. In those cases in which the discharges escape into the nose, the breath is exceedingly offensive, having the odor of a rotten egg, which is due to the presence of hydrogen sulfid gas, liberated by the de- composition of the albuminates contained in the discharges. Blow- ing the nose will sometimes relieve the sense of fullness by causing a flow of the discharges. The more common course is for the discharge to be quite constant, the amount varying from a slight quantity to a considerable amount, and flowing into the nose and throat when lying upon the unafl:ected side. During sleep the discharges are often swal- lowed, producing nausea and sometimes vomiting on rising in the morning. The movements of mastication may also cause a discharge of the pent-up secretions, while taking food, and thereby induce nausea and vomiting. A case of this character came under the care of the writer some years ago, and the gentleman related that he had not taken a meal with his family, for this reason, and on account of the fetid odor of his breath, for more than six years. The teeth of the affected side are often sore and painful to percus- sion, even though they may not be factors in the production of the disease. This is a point that should be borne in mind when conduct- ing an examination in a case of this character. When the disease is due to lesions of the teeth, the affected ones are usually more sensitive and painful to the percussion test than are those adjacent to them; yet in exceptional cases, the most careful examination may fail to detect a special tenderness in any of the teeth. Diagnosis. — The diagnostic signs are, the location and the char- acter of the pain, unilateral discharge from the nose (except where both antra are afl'ected, when it would be in all probability bilateral), swell- ing of the face, bulging of the diseased side of the vault of the mouth, tenderness of the affected side of the face, crepitation over the thinned walls of the antrum, frequently the presence of diseased teeth, soreness of the teeth to percussion, protrusion of the eyeball, fetor of the breath, nausea or vomiting on rising in the morning. These conditions are not always well marked in every case, but a sufficient number will be present in a majority of them to establish a diagnosis. DifiFerential Diagnosis. — The diseases of the maxillary sinus which may be confounded with abscess or suppuration of this sinus are angiomata, malignant neoplasms, and bony tumors. Tumors of the antrum can be very positively diagnosed from suppuration and mucous 350 SURGERY OF THE FACE, MOUTH, AND JAWS. engorgements by means of the electric mouth-lamp or stomatoscope. The patient being seated in a dark room, the lamp is placed in the mouth, and the lips closed over it, when, if the tissues are in a normal condition, the light will be quite readily transmitted through the cheeks and lower eyelids. If the antrum is filled with fluid, like pus or heavy mucus, the light is somewhat impeded, while if it be filled with a solid tumor, it is entirely obstructed. An exploratory puncture or incision with the exploring needle or small scalpel will often immediately clear up the diagnosis. Prognosis. — The prognosis is usually favorable, except in those cases in which the discharges have burrowed into the cranial cavity. In a majority of cases a cure is effected by slow degrees, sometimes requiring months, and even one or two years, to^ accomplish it. The general condition of the patient is an important factor in the prognosis. A tubercular or scrofulous diathesis, or a generally debilitated condi- tion, militates against a rapid cure. In persons of otherwise good health a cure is sometimes effected in a few weeks; the majority, how- ever, extend over a much longer period. Treatment. —For the successful treatment of suppuration or ab- scess of the maxillary sinus, three conditions must always be secured, viz: First, the removal of the exciting cause; second, the complete evacuation of the contents of the sinus; and, third, the establishment of perfect drainage. Failure to secure these conditions is among the principal reasons why the treatment of this disease is many times so unsatisfactory. In order to secure these conditions the sinus should be opened at its most dependent point, which is at the floor of the cavity opposite the alve- olus of the second molar tooth, and if bony septi are present, these should be broken down with the curette or surgical bur. The simplest way of entering the antrum is by extracting the first or second molar tooth, and enlarging and deepening the alveolus of the anterior buccal root. This alveolus is selected because it carries a larger root than the posterior one, hence is more available for this purpose. If these teeth are sound, it is preferable to make an opening between the posterior buccal root of the first molar and the anterior root of the second, as suggested by Heath, rather than to needlessly sacrifice sound teeth. On the other hand, all diseased teeth and roots upon the affected side should be extracted at once, as they are more than likely to be the pri- mary cause of the disease; and if they should not be directly respon- sible, they are usually a source of irritation, and may therefore become a secondary cause of the lesion. In opening the antrum, the ordinary trocar fitted with a canula is a very satisfactory instrument if properly handled. There is danger, however, when the bone is thick and hard, requiring a considerable DISEASES OF THE MAXILLARY SINLIS. 35I amount of pressure to penetrate it, that it may suddenly break through, and the point of the trocar penetrate the floor of the orbit. This acci- dent may be guarded against by so holding the instrument that it can only penetrate to the desired depth, or an adjustable metal guard can be placed upon the instrument, which will effectually prevent its going beyond the depth to which it is desired to penetrate. The trocar. Fig. 129, was devised by the writer expressly for this purpose. The guard is fitted into the handle by means of a screw, which makes it possible to penetrate the antrum at any desired depth, while the handle is fitted with a device operated by the thumb which carries the canula forward to the tip or the trocar, and allows the trocar to be withdrawn, leaving the canula in position. The most satisfactory method of opening the antrum is by the use of a spear-pointed drill, revolved by the surgical engine. With this instrument the surgeon can feel his way through the bone so delicately Fig. 129. Au'iHOR's Antrum Trocar with Guard, (Reduced. 1 and surely that he can tell when the drill is about to enter the cavity, and even when it pierces the mucous membrane, so that by this method accidents are reduced to the minimum. In order to secure free dis- charge, the drill should leave an opening at least one-fourth of an inch in diameter. This is about as large an opening as can be secured be- tween the roots of the first and second molars without injuring the roots of these teeth; but when the opening is made through the alve- olus, there is no reason why it may not with advantage be made larger. When the probe reveals the presence of bony septi, it becomes neces- sary to make the opening somewhat larger. Under suc\i circum- stances, the septum of bone between the anterior and posterior buccal alveoli can be cut through with a long side-cutting bur, which is an enlargement in shape of the dentist's fissure bur. (See Fig. 115.) This will give entrance to a small spoon curette, or the round surgical bur, with which to break down the bony septi. An opening which is made through the external wall of the an- trum between the roots of the first and second molars is preferable to one made through the alveolus of a tooth, for the reason that in the former case the cheek, falling over the opening made through the ex- ternal wall, is a protection against the entrance of food, while in the latter, unless it is kept plugged, foreign substances constantly enter, which, acting as irritants, tend to keep up the inflamniator_\- symptoms. 352 SURGERY OF THE FACE, MOUTH, AND JAWS. Plugs and drainage-tubes are a source of great annoyance and inconvenience to the patient, and, in the opinion of the writer, are many times a source of irritation, thus retarding the progress of the cure. When the opening is through the alveolus of a tooth, plugs or tubes with stoppers are necessary to prevent the ingress of food; at the same time they prevent the free discharge of the secretions. This condition, in relation to an abscess in any other location of the body, would not be tolerated by an enlightened surgeon for a moment, as it would defeat the very object for which drainage was established. The preference, therefore, should be given, when circumstances will permit, to that operation for opening the antrum which will not require the use of plugs or tubes in the after-treatment. When a drainage- tube is employed, no better form can be chosen than that suggested by Talbot, Fig. 130. Fig 130 Talbot s Antrum Tlue (After Talbot Some surgeons prefer the method of opening the antrum through the nose, as near to the natural entrance as possible, one purpose of which is to render it impossible for infection to occur through the moutii, as is feared if an opening is made into the antrum through this cavity. This method seems to be open to several important objec- tions, on account of the difificulties in the way if it becomes neces- sary to break down bony septi, or to curette the surfaces of the sinus. This method, however, has its advantages in the treatment of mucous engorgements, for all that is necessary in these cases is to re-estab- lish the discharge of the secretions into the nose; but in those more serious conditions, like abscess of the antrum, from various causes, entrance through the mouth is to be preferred, because an opening can be made as large as the circumstances require, — large enough to admit the index finger, or larger, as sometimes becomes necessary, especially where septi are to be broken down, or search made for foreign bodies DISEASES OF THE JIAXILLARY SINUS. 353 or malposed teeth. Under circumstances like these, the tactile sensa- tion of the finger is a much surer guide to a correct understanding of existing conditions than a probe or a sound, which are the only means of detecting these conditions when entering the antrum through the nose. General anesthetics are frequentl)' necessary in operations for opening the antrum, especially in those cases requiring the extraction of teeth, the cutting of bone to any considerable extent, or curetting the mucous membrane. In those cases requiring only the puncture of a thin wall of bone, the local application of cocain by hypodermic injection will answer a good purpose. The writer has made several quite extensive operations upon the floor of the antrum with no other anesthetic than cocain: yet he feels safer with ether or chloroform than with cocain, and therefore does not recommend its use when re- peated injections would be necessary to maintain the condition of local insensibility, for fear of establishing the toxic symptoms of the drug. Solutions of cocain of a greater strength than 2 to 4 per cent, are never required in these operations. After an opening has been made into the antrum, it should be thoroughly irrigated with some bland, non-irritating antiseptic solution. The writer prefers the Thiersch solution, or the boric acid solution. Irrigation should be continued until the fluid runs clear. The ordi- nary irrigating bag, with rubber tubing and a glass nozzle, is preferable to any of the syringes recommended for this purpose. Solutions of bichlorid of mercury and carbolic acid have certain disadvantages which should cause them to be discarded in all diseases of the mucous membrane. The bichlorid of mercury solutions are more or less irritating to all mucous surfaces, if of a strength sufficient to be of real value as a germicide, and have the added disadvantage of being readily absorbed in sufficient quantities to produce toxic symp- toms, if by chance the fluid should be retained in the sinus. Carbolic acid is also irritating to mucous surfaces when of a strength to be val- uable for antiseptic purposes. A solution of less than 5 per cent, would be of little value as a germicide, while one of that strength would be irritating. The employment of irritating solutions is, in the mind of the writer, another reason why the inflammatory conditions of the max- illary sinus are so tedious and difficult to cure. This opinion has grown out of a considerable experience in the treatment of this class of diseases, and experimenting with the various methods of treatment with drugs suggested by the recognized authorities on this subject. The peroxid of hydrogen, and medicinal pyrozone, are remedies which the writer has lost confidence in for this ptirpose, — not that they are not good scavengers or good disinfectants, but that they frequently 24 354 SURGERY OF THE FACE, MOUTH, AND JAWS. cause great pain and irritation, even when diluted, from the rapid evolution of oxygen gas, and the consequent pressure upon a highly- sensitive membrane when they are injected into the antrum, especially in those cases where the opening made for evacuation and drainage is necessarily small. In the after-treatment the same bland solutions, or sterilized water alone, are to be preferred to solutions which are in the least irritating or over-stimulating. Irrigation should be performed three or four times per diem for the first few days after the operation, preferably after meals, and on rising in the morning. As the symptoms subside, irrigation may be gradually decreased to once per diem, and finally withdrawn altogether. Insufflation with powders is not to be recommended, for the reason that there is no assurance that they are invariably dissolved in the secretions. Materials of this character, if left undissolved in the antrum, would be likely to act as foreign bodies, thus continuing the irritation and preventing a cure. No anxiety need be felt in reference to the final closing of the opening made into the antrum. There is more difficulty experienced, as a rule, in keeping it open for a sufficient length of time for proper treatment, except in those cases where plugs or tubes are used. In exceptional cases, where large openings have been made, or plugs and tubes have been used, it may become necessary to stimulate granulation by touching the edges of the opening with nitrate of silver or the galvano-cautery, followed by repeated applications of tincture of iodin, or it may be closed by a plastic operation. The treatment of mucous engorgements is less difficult, from the curative standpoint, than suppurative conditions of the antrum, except in those cases where the secretions have been retained for a period sufficiently long for decomposition to have taken place, when the in- flammatory condition assumes a chronic type, rendering the treatment much more difficult and tedious. In the ordinary cases of mucous engorgement of the antrum re- sulting from acute coryza, or la grippe, drainage can be secured by expanding the natural opening into the nose. This may be accom- plished by passing probes or sounds of gradually-increasing diameter. To avoid the paroxysms of sneezing, and the pain induced by the intro- duction of the probe, the mucous membrane should be sprayed with a lo per cent, solution of cocain. When the natural opening cannot be found,- — and it is not always an easy matter to find it and introduce the probe, — the sinus can be entered at one of those points already indi- cated for draining this cavity, preferably between the roots of the first and second molar teeth. In the experience of the writer, this simple form of antral disease DISEASES OF THE MAXILLARY SINUS. 355 is the most amenable to treatment; thorough drainage alone being all . that has been required in many cases to effect a complete and perma- nent cure in from two to three weeks. In the more persistent cases, daily irrigation with the nasal douche, charged with sterilized water or some of the bland antiseptic solutions, will be necessary. If a purulent condition of the secretions should follow the opening of the antrum, it is certain that the condition first mentioned has not been secured; upon a more careful examination it will be discovered that either com- plete evacuation has not been secured on account of dividing septi, or not having punctured the cavity at its most dependent point; or that the drainage is imperfect, either from the closure of the opening in the mucous membrane, the formation of a clot in the wound, or the en- trance of foreign substances or septic bacteria. It is often difficult to maintain a free opening in the mucous lining of the cavity by the ordi- nary methods, as the tendency of wounds in this tissue is to heal very quickly. To obviate this difficulty, the sides of the opening may be cauterized with the electro-thermal cautery; two or three applications may be necessary to secure an opening that will remain patulous for a sufHciently long period to accomplish a cure. REVIEW. CHAPTER XXXIV. What is the character of the pain in suppuration of the antrum? What is the cause of the parchment-hke crepitation? What is the cause of the protrusion of the eyeball? What constitutional symptoms accompany acute cases? What is the character of the discharge? When the discharges do not escape into the nose, what result is likely to follow? At what point does rupture take place? Which walls oflfer the least resistance? What complications usually follow rupture of the antrum? What is the result when the discharges enter the brain? What characteristic odor always accompanies purulent discharges from the antrum? If this characteristic discharge is present, but no swelling to indicate which antrum is affected, what ether symptoms will indicate it? Give the diagnostic signs. What conditions of the antrum might be mistaken for suppuration of this sinus? How may they be differentiated from suppuration of the antrum? Is artificial light transmitted through the normal tissues of the superior maxillary bone when the light is placed in the mouth? 356 SURGERY OF THE FACE, MOUTH, AND JAWS. Would the light be transmitted if the antrum was filled with fluid? If filled with an abnormal growth? What is the prognosis? W'hat constitutional conditions militate against a rapid cure? What three conditions must be secured to successfully treat this disease? Where is the best point to enter the antrum? What other points have been suggested? If the teeth' are all in a healthy condition would it be advisable to extract an}' of them for the purpose of entering the antrum, and why? Under these circumstances what location should be chosen for this pur- pose? What advantage has this location over opening through the alveolus? What instruments are necessary for opening the antrum? How are bony septi to be broken down? What are the disadvantages of plugs and drainage-tubes? What are the disadvantages of making an opening through the nasal wall? What is the treatment after the antrum has been evacuated? What solutions are best for these cases? What are the objections to carbolic acid and bichlorid solutions? What are the objections to peroxid of hydrogen solutions? How often should irrigation be performed? What are the dangers from the insufflation of powders? By what means may a large opening be finally closed? What method of draining the antrum for the relief of mucous engorgements is recommended? How can this expansion be accomplished? Where should the antrum be penetrated if the natural opening cannot be found? What other means beside drainage is sometimes necessary to restore the cavity to a normal condition? What are the probable causes of a purulent discharge following the opening of the antrum? By what means may the mucous lining be prevented from closing the open- ing made into the antrum? CHAPTER XXXV. DISEASES OF THE AIAXILLARY SINUS (Continued). Syphilitic Ulceration of the Antrum of Highmore. — This is a condition of rare occurrence. Tlie antrum, however, sometimes becomes involved when the roof of the mouth is the seat of the destruc- tive syphiHtic process, or when the turbinated bones and the nasal wall of the antrum are afifected. This manifestation of a syphilitic infection is generally the result of the tertiary form of the disease, and is usually an extension of the af- fection from the nasal fossa. The writer is of the opinion that syphil- itic ulceration of the mucous lining of the antrum is never found except as a tertiary manifestation and an extension of the disease already located in contiguous parts, although he is fully aware that in giving expression to this opinion he places himself in opposition to the views of some excellent observers. In support of this position, reference is made to Morrow, who says, "Familiar sequelae of tertiary syphilis are perforation of the cartilaginous and bony septum, and the palatine roof; caries and necrosis of bone, ozena, and extetision of the disease to the antrum, and other accessory cavities, and to the bones of the face and skull." Garretson says, after a careful examination of the syphilitic pa- tients in Blockley Hospital, Philadelphia, extending over a whole year, he could not find a single case of syphilitic disease of the antrum in which the disease had its origin in this sinus. The manifestations of syphilis are quite common in the nasal cav- ity, but they belong essentially to the tertiary stage, the earlier symp- toms being very rarely manifested in this region. Bosworth does not believe the secondary stage of the disease, in the form of mucous patches, ever appears in the nose. It is more than likely that such secondary manifestations of the disease are never found in the antrum of Highmore; though positive or negative demonstration of this statement could not be furnished except by a long and careful search for the proof upon persons who had died while suffering from secondary lesions of the disease. Such exami- nations may have been made and the results published, but the writer does not recall any published account of such a line of investigation. 357 358 SURGERY OF THE FACE, MOUTH, AND JAWS. It is fair, however, under the circumstances, to reason from anal- ogy, that inasmuch as the same type of mucous membrane Hnes the maxillary sinus that lines the nasal passages, and that the secondary lesions of the disease are very rarely if ever found in the nasal passages, the same immunity in all probability is possessed by the antral lining membrane. The tertiary manifestations of syphilis in the nose and antrum usually develop in from five to fifteen years after the initial lesion, or the primary stage of the disease, in the formation of deep- seated ulcerations of a grave and destructive character, pursuing a rapid course, causing a more or less extensive destruction of tissues, and involving the cartilages and the nasal and turbinated bones to such an extent as to cause most horrible deformities. The disease is character- ized by suppuration and necrosis, accompanied by the discharge of masses of pus, blood, and necrotic tissue, and a most intolerably fetid and penetrating odor which makes the patient an offense to himself and to every one who comes near him. There are two varieties of syphilitic ulceration of the nose in the tertiary form of the disease, viz: superficial ulcer, and deep-seated ulcer. The superficial ulcer is usually found upon the mucous membrane covering the cartilaginous septum. It may destroy the cartilaginous septum and then attack the bony septum, resulting in a more or less complete destruction of this portion of the nose, though it rarely ex- tends so far, being confined generally to the cartilaginous septum. The deep-seated ulcer is by far the most serious and destructive form of tertiary syphilis found in the nasal cavity. It is due to the for- mation of gummata in the deeper layers of the mucous membrane, which later become softened and break down, developing an ulcerative action of a rapid and destructive type. This form of ulceration is usually found upon the turbinated bones, and is characterized by deep excavating ulcers with ragged, overhang- ing edges; the surface of the ulcer is bathed with yellow pus mingled with fragments of blackened gangrenous tissue; and the surrounding mucous membrane is highly congested, often turgid and purplish in color. The ulcerative process rapidly penetrates to the periosteum and the bone, also extending laterally with equal rapidity, often causing extensive necrosis and exfoliation of the osseous structures of the nose, and sometimes involves the accessory sinuses. There is always an ofifensive discharge, giving the odor of decom- posing pus and dead bone, accompanying the disease, which makes the presence of these poor unfortunates almost intolerable. The tendency to the formation of crusts or masses of dried pus, mucus, blood, and gangrenous tissue, which adhere closely to the surface, and are exceed- DISEASES OF THE MAXILLARY SINUS. 359 ingly difficult to dislodge, is another characteristic of the disease. These masses when expelled are in odor and appearance most disgusting and nauseating. As the disease progresses, the nasal wall of the antrum may become involved in the destructive process, which may finally extend to the mucous membrane lining this cavity. When the antrum becomes involved there is usually as an indication a swelling at the angle of the nose and cheek, and in those cases where the nasal wall of the sinus has been lost by necrosis, this fact may be ascertained by exploration with a probe. Diagnosis. — There are no characteristic symptoms of the disease located in the antrum, other than the swelling at the angle of the nose and cheek, that are distinguishable from those found in the nose. The more common location of the disease in the superior maxillary bones is the floor of the nasal fossa, which may be destroyed, leaving a more or less extensive opening between the nose and mouth, making the swallowing of food and liquids difficult, and greatly impairing the voice. The tertiary form of the disease rarely involves the velum palati, the septum alae narium, or the cutaneous surfaces; but is usually con- fined to the cartilaginous septum, the inner nasal bones, the turbinated bones, and the superior maxilla. The deformities which result are the falling in of the nose caused by the loss of its bony supports, and the perforation of the hard palate just referred to. One case only has the writer seen of syphilitic ulceration of the antrum, which did not have its starting point in the nasal fossa. The patient was a man who had been inoculated twenty years before. The disease began as an ulceration of the mucous membrane covering the hard palate opposite the right secofid molar tooth, resulting in perfora- tion of the hard palate and antrum, with loss of the entire floor of the sinus, together with the teeth, from necrosis. Figs. 131 and 132 are illustrations of the secondary form of the disease which had their com- mencement in the velum palati in the form of ulcers, and later involved the palate bones. In Fig. 131 the opening originally extended consid- erably farther forward, but this has been gradually filled up by the pro- cess of granulation. Differential Diagnosis.- — Syphilis of the nose and antrum is often diagnosed as fetid catarrh, ozena, and other forms of disease which are accompanied by foul-smelling odor and discharges. The diagnosis, however, is rendered quite simple if a good view of the nasal cavity can be obtained through the anterior nares, as the parts most likely to be affected are generally within the range of vision through these open- ings. In order to obtain a good view of the parts, the crusts and dis- 360 SURGERY OF THE FACE, MOUTH, AND JAWS. cliarges must first be removed, as these cover and conceal the condi- tions of the tissues beneath. If tlie disease is fetid catarrh or ozena, the mucous membrane, the septum, and the walls of the nasal cavity Fig 131 Syphilitic Ulceration of the Velum Palati involving the Posterior Border of the Palate Boxes. Syphilitic Ulceration involving Portions ok the Palate Bones and the VelUiM Palati. will be found intact; while on the other hand, if it is syphilis, ulcera- tions upon the septum or turbinated bones or necrosis of bone of greater or less extent, will be discovered. DISEASES OF THE MAXILLARY SINUS. 36I This fact, however, must be borne in mind in making a diagnosis, viz: that ulceration never occurs except as a result of some general ■dyscrasia like syphilis, tuberculosis, cancer, the exanthemata, etc.; there is, however, no danger of making an error in the diagnosis, for differ- entiation is made comparatively simple by the presence of symptoms which are characteristic of one or the other of the diseases. It is safe therefore to say if ulceration is found without any of the general symp- toms of impaired health which accompany tuberculosis, cancer,' or the exanthemata, that the disease is in all probability due to syphilis, even though no positive history of infection with the syphilitic virus can be established, for it is often dififtcult after the lapse of so long a period to arrive at a definite history of the presence of the primary lesion or of secondary manifestations. Treatment. — The systemic treatment of tertiary syphilis is confined to the iodid of potassium in gradually increasing doses, beginning with 10 to 15 grain doses three times per day, adding three grains each day until the toxic manifestations of the drug appear, when a marked improvement in the symptoms is usually observed. Mercury is contra- indicated in this form of the disease. It is well occasionally to with- draw all systemic medication. Tonics, sea air, a generous diet with wine or malt liquors, are always indicated, and occasionally this is all that is necessar}'. The local treatment of syphilitic ulceration of the nose and antrum should be directed to securing cleanliness of the parts, by removing secretions, crusts, and pieces of dead bone which are sources of irrita- tion, stimulating ulceration and retarding the reparative process. The removal of the crusts is greatly facilitated by the use of the post-nasal syringe and the douche charged with antiseptic solutions, — the milder forms, like the Thiersch and the boric acid solutions, being preferable. \Mien the antrum is involved, this cavity can usually be reached through the nose by means of a curved nozzle attached to the syringe or douche. Boric acid solution and cinnamon water, equal parts, is a good disinfectant and deodorizer, and may be used to best advantage with the atomizer. The rehioval of dead bone should be accomplished at as early a period as possible, but the writer does not believe it is the part of a wise conservatism to attempt its removal until separation has taken place. Necrosis of the Walls of the Maxillary Sinus. — Necrosis of the walls of the maxillary sinus is a diseased condition of somewhat com- mon occurrence, for the reason that there are so many lesions, either of an idiopathic, traumatic, or specific origin, which aft'ect this part of 362 SURGERY OF THE FACE, MOUTH, AND JAWS. the face and have a tendency to result in inflammatory conditions of the bone, and finally in necrosis. Necrosis of the walls of the antrum may occur as the result of peri- ostitis, induced by certain diseases of the teeth, such as septic perice- mentitis, or alveolar abscess; local arsenical poisoning caused by the escape of the drug into the surrounding tissues when used for the pur- pose of, devitalizing the tooth-pulp; fractures resulting from the extrac- tion of teeth contiguous to the antrum; rupture of the walls of the antrum from the accumulation of pus or other fluids in the sinus ; gun- shot wounds and other injuries causing crushing and comminution of the walls of the antrum; tuberculosis, syphilis, the exanthemata, and mercurial and phosphorus poisoning. The walls, of the antrum most often found necrosed are the nasal wall, caused by specific disease extending from the nasal fossa; the superior wall or orbital plate and the inferior wall or floor of the sinus, from rupture induced by accumulated fluid. The floor of the antrum is also quite frequently the seat of necrosis as a result of the diseased con- ditions of the teeth already mentioned, and from surgical violence in extracting the teeth of this locaHty. More rarely the anterior and pos- terior walls become necrosed from inflammatory conditions of the sinus and from traumatic injuries. Symptoms.- — -The symptoms of necrosis of the walls of the maxil- lary sinus are the same as in necrosis located in other portions of the body; briefly: a history of a previous acute inflammation, with great pain, swelling, and discharge of thick pus. Present conditions, pain slight, swelling of the overlying tissues, discharge of oiTensive smell- ing, purulent pus, numerous sinuses, and denuded bone, which may be felt with a probe passed through the sinuses. Sinuses which lead to dead bone always present a granular appearance at the surface, and have a tendency to bleed on being touched. The most frequent locations of the sinuses in necrosis of the antrum are the roof of the mouth, alveolar ridge and external integu- ment in the regions of the inner canthus of the eye, and the infraorbital foramen. Ugly scars often result from the healing of these sinuses when located in the latter regions, and not infrequently cause ectropion of the lower eyelid. Treatment. — The operative treatment does not differ essentially from that for the same conditions in other locations, except that every means should be employed to prevent the formation of unsightly scars upon the face. A word of caution may not be amiss to the young practitioner in relation to the proper time to operate for the removal of dead bone in the region of the face. A safe rule to follow is not to attempt to remove the necrosed bone until separation has taken place between the living and dead portions. Less deformity, in the judgment DISEASES OF THE MAXILLARY SINUS. 363 of the writer, follows such procedure than when an operation is per- formed before this process of exfoliation has been completed. It is wise to frequently examine the sequestrum to ascertain if separation has taken place, and as soon as this can be demonstrated it should be removed. The constitutional treatment must be directed to the build- ing up of the health of the patient and controlling the tendencies of peculiar d3'scrasia or constiutional vice. A case at present under treatment, which gave the writer consider- able trouble from its rapid extension until the real nature of the disease was discovered, may be used as an illustration upon this point. The patient, a man forty years old, was referred to the writer by a profes- sional friend. At the time he was first seen there was considerable swelling of the right side of the face below the malar bone, and the teeth and external plate of the alveolar process had been removed between the right central incisor and the first molar of the same side. From general appearances, tertiary syphilis was suspected, but he de- nied ever having contracted the disease, and his word was taken upon that point, and only general tonics administered. At the end of ten days the disease had extended upward to the inferior border of the orbit and to the nasal bone, and backward, involving the floor of the antrum and the palate process to the median line. He was then placed upon the iodid of potassium, 15 grs. three times per diem, increasing the dose each day 3 grains; at the end of two weeks there was a very marked improvement in the conditions, the swelling was less, the disease had not extended beyond the limits just mentioned, exfoliation had already begun, and the case bade fair to make a good recovery, but with the loss of a considerable portion of the superior maxillary bone. It is possible that this might have been prevented had the iodid been admin- istered at first, as would have been done but for the positive assurances of the patient. The wiser plan therefore, in all doubtful cases, regard- less of the statements of the patient, be they never so positive, is to immediately begin a course of anti-syphilitic treatment. REVIEW. CHAPTER XXXV. Is syphilitic ulceration of the antrum rare or common? How does the antrum become involved? During which stage of syphilis does the antrum become involved? Are secondary symptoms of the disease ever found in the nose? Is it likely that the symptoms are ever found in the antrum? 364 SURGERY OF THE FACE, MOUTH, AND JAWS. What reasons are given for this opinion? How soon after inoculation does the tertiary stage of syphilis develop in the nose and antrum? How is it manifested in these locations? What is the character of these ulcerations? By what are they always accompanied? Name the number and varieties of syphilitic ulceration of the nose and antrum. Where is the superficial ulcer usually located? How does it afifect the cartilaginous septum? Does it attack other tissues? To what portion of the nose is it usually confined? What is the difference in character between the superficial and deep-seated ulcer? What is the origin of the deep-seated ulcer? What is the character of its progress? Where is it most frequently located? Describe the clinical appearance of the deep-seated ulcer. What is the character of the discharges? How does the antrum become affected? What are the symptoms when the antrum is involved? Which portion of the superior maxillary bone is most frequently the seat of the disease? What portions of the nose are most often involved? What other diseases may simulate syphilis of the nose and antrum? What is the differential diagnosis in fetid catarrh? What is it in tuberculosis, cancer, and the exanthemata? What is the systemic treatment for tertiary syphilis? What is the local treatment for the disease in the nose and antrum? Through what channel is the antrum reached? What solution is recommended as a good disinfectant and deodorizer? When should the necrosed bone be removed? Is necrosis of the walls of the antrum common? What reasons are given for this frequency? What are the causes of necrosis of the walls of the antrum? Which walls of the antrum are most often necrosed? What are the most common causes of each? What are the symptoms of necrosis of the antrum? Where are the sinuses most frequently located? What is the peculiarity of a sinus which leads to necrosed bone? What is the result of the healing of sinuses opening through the integu- ment? What is the surgical treatment? When is the proper time to remove dead bone, located in this region? What is the line of general treatment? CHAPTER XXXVI. CYSTIC TUMORS OF THE MAXILLARY SINUS. The maxillary sinus is not infrequently the seat of various forms of cystic and solid tumors, but their presence is rarely discovered until they have obtained a considerable size, filling the sinus and expanding its walls. Attention is drawn to the presence of solid tumors by the swelling, and the pain which usually accompanies the formation of these growths and certain forms of malignant neoplasms. Among the cystomata or cystic tumors found in the antrum may be mentioned Mucous Cysts and Polypi. Mucous Cysts of the Antrum, the hydrops antri or dropsy of the antrum of the old writers, is a disease resulting from the cystic degen- eration of the glandular follicles which are very numerous over the entire mucous membrane lining the cavity. The disease is character- ized by the presence of a dark straw-colored, glairy fluid, sometimes gelatinous, and of the consistence of egg albumen, frequently contain- ing considerable quantities of cholesterin which appear in the form of small flakes, floating in the fluid. The accumulation of the fluid is slow, which causes a painless enlargement of the face upon the affected side, with expansion of the antrum and thinning of its walls. The disease was formerly thought to be caused by the retention of the natural secretions, but modern research has proved this view to be incorrect. The retention of the, natural secretions is generally the result of acute inflammatory conditions of the mucous membrane of the nose which have extended to the sinus, and produced occlusion of the osteum maxillare. In cystic degeneration of the mucous membrane of the antrum there is frequently an aggregation of small cysts which makes the treat- ment of the case a more difficult one than when the sinus is filled with a single cyst. In some cases the cyst seems to be developed within the bony wall of the antrum, or between the bone and the periosteum, and by lateral extension fills the cavity and makes it possible under such circumstances to mistake the cavity of the cvst when it is opened for the sinus itself. Occasionally serous cysts develop at the roots of devitalized teeth as a result of chronic inflammation. Heath mentions a case reported 365 366 SURGERY OF THE FACE, MOUTH, AND JAWS. by Fischer in which he was able by post-mortem examination to clearly trace such a cyst which occupied the entire antrum, but had no connection whatever with its walls, and was attached only to the roots of a molar tooth by its pericementum. Cysts of this character, though not so extensive in size, are fre- quently found in both the upper and lower jaws; at least this has been the observation and experience of the writer. One somewhat similar case to that mentioned by Heath, occurring in his private practice, may be used as an example of the difficulties sometimes experienced in mak- ing a correct diagnosis. Mrs. O., thirty-five years of age, was referred for treatment of an extensive enlargement of the right side of the face in the region of the antrum, and extending forward to the ala of the nose. There was some difficulty in breathing through the right nostril, due to bulging of the nasal wall of the antrum. The contour of the palate was normal. On examination of the teeth, it was found that the lateral incisor and the first bicuspid were both devitalized, the pulp- canals of each having been filled some years before. Percussion of these teeth elicited tenderness in the first bicuspid, but not in the lateral. The swelling of the face had been noticed for more than a year, and it was slowly increasing in size. There was no discharge from the nose, and no sinus leading to the enlargement. The tumor was firm and un- yielding. These symptoms all pointed to the presence of a solid tumor of the antrum. As a more positive means of diagnosis an exploratory puncture was decided upon, and inasmuch as the first bicuspid tooth was badly decayed, this was extracted with the intention of puncturing the floor of the antrum through its alveolus, but upon removal of the tooth an ounce or more of a thick, tenacious, straw-colored fluid, filled with flakes of cholesterin, escaped into the mouth. The opening was therefore enlarged with a surgical bur, and the surface of the antrum curetted under the local anesthetic effect of cocain. The wound was afterward kept open for several weeks, the antrum irrigated twice per diem, when the fullness of the jaw subsided and the opening in the antrum was permitted to close. Six months later the patient returned with a recurrence of the disease, and the extraction of the lateral incisor was advised on account of the location of the swelling, which was greatest under the ala of the nose. This she declined to have done, but as a compromise, submitted to the opening of the root-canal. In this way the cyst was reached, and a considerable discharge followed of a fluid similar to that evacu- ated from the antrum. The wall of the cyst was then punctured near the apex of the root of the tooth, and a further discharge followed. Injections of a 10 per cent, solution of iodin and glycerol were used twice a week for a month, with marked improvement, after which the opening-was allowed to close and the root of the tooth was refilled. CYSTIC TUMORS OF THE MAXILLARY SINUS. 367 A few weeks later the patient returned again with the face much swollen. At no time did she complain of pain except during the treat- ments. This time the lateral incisor was extracted, and it was found that a large cyst had been formed at the apex of the root, communicat- ing with the antrum. A counter-opening was made into the sinus at a point near the apex of the alveolus of the lost first bicuspid tooth, and the cyst and antrum were curetted and then irrigated with Thiersch solution. Following the operation there was a slight discharge of the typical secretion of cystic tumors for a few days, when it ceased alto- gether, and the openings were allowed to close. At the end of five years there had been no return of the disease. Symptovis and Diagnosis. — The disease is of slow and painless growth, the very antithesis of suppuration or empyema of the antrum, which is rapid and painful in its development. Sooner or later the cheek becomes prominent and rounded, sometimes considerably en- larged ; protrusion of the eye may occur, the nose is forced to the oppo- site side, the nasal fossa becomes occluded from bulging of the nasal wall of the antrum, and sometimes the palate is depressed to such an extent as to interfere with deglutition. The tumor may be soft and elastic in some places, and hard and resisting at others. Pressure over the elastic portions gives the parchment-like crepita- tion which accompanies bone that is greatly thinned and expanded. There is usually no discharge from the nose. In many respects it closely resembles in appearance solid tumors of the jaws. Errors in diagnosis on this account have been frequently made, through which even excision of an entire jaw has been performed, and the mistake not discovered until it was too late to rectify it. The conservative sur- geon will not fail to take the precaution of an exploratory puncture or incision when making the diagnosis of a doubtful tumor, as this will give him positive data upon which to base his opinion so far as the gen- eral character of the growth is concerned. Prognosis. — The disease is prone to recurrence unless the treat- ment is thorough and heroic. The deformity of the face which has been occasioned by the expansion of the bone will gradually but finally disappear after the disease has been cured. Treatment. — The treatment consists of the evacuation of the con- tents of the cyst by free incision at its most dependent portion, curet- ting its inner surface, irrigation with some antiseptic solution, and stimulating injections to promote granulation. In those cases where the distention of the bone has been considerable, a portion of the exter- nal wall should be removed, or crushed in. Irrigation and the stimulating injections should not be discon- tinued until all tendency to the formation of the characteristic discharge has ceased. 368 SURGERY OF THE FACE, MOUTH, AND JAWS. Polypus of the Antrum. — A polypus is a small pedunculated cystic tumor growing from a mucous surface. Polypi of the antrum are similar in structure to those found asso- ciated with the mucous membrane of the nasal passages. There are two varieties, the fleshy and the cystic. They are the result of hyper- trophies — inflammator}' hyperplasia — of the submucous connective tissue and of the mucous membrane. When the tumor arises from the submucous layer the connective- tissue elements will predominate and result in the formation of a fleshy polypus; when it arises from the mucous membrane proper, the glandu- lar structures will be in excess and a cystic form will be produced. An intermediate form is sometimes developed, having a loose fibrous struc- ture with glandular elements, resulting in the formation of a semi- gelatinous polypus which very closely resembles the common form of polypus of the nose. Polypi of the antrum are usually very vascular, and cause considerable hemorrhage when they are surgically interfered with. The disease is not a common one, and yet far more frequent than is generally supposed. Luschka in his investigations found that out of sixty subjects examined by him, five had polypi of the antrum, or one in twelve. Symptoms and Diagnosis. — The symptoms do not differ materially from those of mucous cysts of the antrum. Polypi may be present in the antrum for years, and the patient remain entirely unconscious of the fact until by their size they cause absorption of the nasal wall of the sinus or expansion of the bone, with external deformity of the face. The thin nasal wall of the antrum is the one which most frequently gives way from absorption, induced by the pressure of the cysts which occupy this cavity, and for this reason it is sometimes difficult to determine when the polypus occupies the nasal fossa also, whether it originated in the nose or in the antrum. John Bell, Syme, Vidal de Cassis, and others, have maintained that polypus never originated in the antrum, but was always an intrusion from the nose, while Paget, Fergusson, and others hold the opposite view, their opinions being based upon practical demonstration of the fact. It would seem, therefore, that in most individuals who may per- haps have polypi in the antrum, the growths never reach a size to cause any inconvenience or deformity, and consequently their presence rem.ains unsuspected. When the polypus is of sufficient size to have intruded into the nasal passages, the nostril will be more or less completely occluded. Damp weather seems to cause them to swell and more completely close the nasal passages. Prognosis. — The prognosis of polypi of the antrum is generally CYSTIC TUMORS OF THE MAXILLARV SINUS. 369 considered very good, but according" to Heath in some instances they seem to have a maHgnant character, or at least are the forerunners of malignant disease in the antrum and jaw. The writer's experience has been so limited in this particular direction that he does not feel quali- fied to hazard an opinion upon the matter, therefore accepts the teach- ing of the eminent authority just mentioned, especially as polypus of the nose in certain cases seems to possess a tendency to malignant de- generation. Treatment. — The treatment of polypus of the antrum, if it suc- ceeds, must be somewhat in the nature of a radical operation. Thorough extirpation of the growth, either through the nasal wall, the external wall, or the floor of the antrum, is indicated. The first is to be preferred when it can be accomplished in the thorough manner necessary for a cure, as it does not require an incision through the external tissue of the face nor the loss of several teeth, as would be the case if the sinus was to be reached, on the one hand through the cheek, or on the other through its floor. Considerable difficulty is sometimes experienced in trying to remove such growth in the antrum through the nostril, but with polypus forceps properly curved, and a goodly allowance of skill and patience, the antrum may be .reached through a previously made opening in the nasal wall, and explored to its farthest extremity. There is, however, an element of uncertainty always present in this operation, as to whether the growth has been entirely removed or not. If the antrum is opened through the external wall the superior maxillary bone must be laid bare, by laying back the lip and cheek as in the operation for exsection of this bone, and the wall of the antrum penetrated with a trephine, chisel, or the surgical saw or bur. If the opening is made through the floor of the antrum, two or three teeth must first be extracted, and afterward the bone can be cut away with the surgical burs. A sufficiently large opening must be made to permit exploration with the index finger. The after-treatment consists of the usual irrigation of the sinus with non-irritating antiseptic solutions, until the tissues of the antrum have healed and the external wound has closed. REA'IEW. CHAPTER XXXVI. What varieties of tumors are found in the antrum? Name the common cystic tumors found in this cavity. What is the cause of mucous cyst of the antrum? What are the peculiarities of its formation? 25 3/0 SURGERY OF THE FACE, MOUTH, AND JAWS. What is the character of its contents? Are cysts of the antrum always single? Would such an aggregation render the treatment more difficult? Are cysts of the antrum always developed from the mucous membrane? Describe the other forms of cysts which do not arise from the mucous membrane. Give the symptoms of cyst of the antrum. What are the diagnostic symptoms? How may errors in diagnosis be avoided? What is the prognosis? Describe the surgical treatment. What is a polypus? How many varieties are there? How are they designated? What is the cause of their formation? Which variety is developed from the submucous layer? From what is the cystic variety developed? What is the character of the intermediate variety? All being usually very vascular, what may be expected when removing them surgically? Is the disease common? What was the result of Luschka's investigation upon this point? What are the symptoms? Is the presence of polypi in the antrum always recognized? Which wall of the antrum in these cases most frequently gives way under the process of absorption? May the polypus be located in the nose and enter the antrum by intrusion? Give the opinion of John Bell and others upon this point. What is the opinion of Paget and Fergusson? What takes place in the nasal passages from intrusion of a polypus of the antrum? How are the polypi affected by damp weather? What is the prognosis? Do polypi ever have malignant tendencies? What should be the character of the surgical treatment? Of what should it consist? How may extirpation be accomplished? Which method is to be preferred? Describe the operation for opening the external wall of the antrum. Describe the operation for opening the floor of the antrum. What is the after-treatment? CHAPTER XXXVII. DISEASES OF THE SALIVARY GLANDS. Inflammation of the Parotid Gland, parotitis, or mumps, is a spe- cific infectious disease, which affects one or both parotid glands. It occurs most frequently in young males, and most commonly during the period of adolescence. A diphtheritic form of the disease is some- times observed, but its most common form is the simple inflammation of the gland known as mumps. The disease often assumes an epi- demic character, and spreads throughout schools and communities. Symptoms and Diagnosis.— The affection may be ushered in by a rigor, nausea, elevation of temperature, and a general feeling of lassi- tude. In a day or two there is dull pain at the back of the jaw, and considerable local swelling, which may interfere with mastication and deglutition. In the milder forms of the disease the patient only com- plains of slight stiffness of the jaws, and pain when masticating food or upon taking acids into the mouth ; while the constitutional disturbances may be so slight as to escape observation. The disease may appear first upon one side, then upon the other, or both sides may be affected simultaneously. One attack gives immunity for the future. The pathology of the disease is still in obscurity. The chief danger to be apprehended in this disease is metastasis to the testes, mammae, and ovaries. Happily these complications are rare. In about three per cent, of the cases metastasis of the testes occurs, producing a true or- chitis, which is rarely found as a primary affection under any other cir- cumstances. The duration of the disease is commonly from eight to twelve days; the affection usually terminates by resolution, and rarely ends in suppuration. Inflammation and suppuration of the glands is sometimes a sequel of typhoid fever, puerperal fever, and erysipelas, and of scarlet fever and variola in children ; or it may be associated with pyemia. Involvement of the neighboring lymphatics in these cases is to be expected. Under such circumstances the disease is attended with great prostration, high temperature, and delirium. The pus coming from such abscesses is of fetid odor. Prognosis. — The prognosis in the latter cases is very grave indeed, for if the disease is left to itself the abscess may open into the auditory 371 372 SURGERY OF THE FACE, MOUTH, AND JAWS. meatus, or, as an exceptional complication, it may pass downward to the chest, or extend in an upward direction along the sheath of the carotid artery to the skull, or behind the pharynx, or upward to the temporo-maxillary joint. Treatment. — In the milder form of the disease the only treatment that is required is protection from taking cold. In the more ordinary form, absolute rest and protection from sudden change of temperature are demanded. If the temperature runs high, this should be controlled by appropriate reinedies. Dry heat applied to the side of the face in the form of heated flannels, a hot brick wrapped in flannel, or a rubber bag filled with hot water, will mitigate the pain. Liquid food will be required for a few days. Medicines beyond a saline cathartic and anodynes are rarely needed. Occasionally the attack will leave the patient in a debilitated condition demanding tonics. In the more seri- ous form of the disease, involving suppuration of the glands, the pus should be evacuated as soon as fluctuation can be discovered, and the cavity irrigated with bichlorid of mercury solution, i to 2000, drainage provided for, and the wound dressed antiseptically. When the pus is superficially located, it is best to make the incision in a line with the course of the facial nerve, so as to avoid the possibility of producing paralysis of the facial muscles by severing this nerve. If a deep incis- ion is necessary, it should be made upon the line and in front of the external carotid artery. The exhibition of quinin and iron, with nour- ishing food, should constitute the systemic treatment, and in cases accompanied with great prostration stimulants should be freely used. Salivary Calculi. — A salivary calculus is a calcareous deposit in a salivary gland or its duct. These concretions occasionally form within the salivary ducts, and much more rarely within the gland itself. Salivary calculi are seldom found within the parotid gland or its duct. The most common location of these concretions is in the duct of Wharton ; more rarely in the ducts of the sublingual gland. Calculi of the submaxillary and sublingual glands are somewhat rare, but the greater number of the reported cases have been found associated with the submaxillary glands. Fiitterer found one hundred and fifty-eight cases of salivary calculi in the sub- maxillary and sublingual glands, mentioned in medical and surgical literature, but he could only secure access to the full reports of sixty- seven of this number. Out of the sixty-seven cases, he found nine were located in the submaxillary gland itself; six were found in the sublin- gual gland or its ducts, and the remainder — fifty-two — were located in the duct of Wharton. Six cases only of calculi in the parotid gland or its duct were found in this search. To recapitulate: Out of seventy- three cases of salivary calculi, affecting the parotid, submaxillary, and sublingual glands and their ducts, six were associated with the parotid DISEASliS OF THE SALIVARY GLANDS. 373 or the duct of Stenson; nine with the submaxillary gland alone; six with the 'sublingual gland or its ducts, and fifty-two with the duct of Wharton. Salivary calculi are seen most frequently between the ages of twentv and forty years. The youngest person reported in the cases gathered by Fiitterer in which a calculus was found, was twelve years of age, and the oldest was seventy years. Burdel reported a case to the French Academy, in which a concretion was found in the sublingual duct of an infant only three weeks old. This calculus was about the size of a grain of wheat, yellow in color, its surface granular, wrinkled, and apparently formed of minute cones cemented together at their base. The analysis showed it to be composed almost entirely of cal- cium phosphate, and a small proportion of nitrogenous organic matter. This no doubt was a concretion of pre-natal formation. Causes. — The causes of salivary calculus may be the presence of a foreign substance lodged in the duct, or bacteria, most likely the Leptothrix buccaUs. Fiitterer was unable to demonstrate leptothrix, but he still argues that they are the most likely nidus around which the deposit is formed. The presence of a foreign substance in the center of the calculus has been demonstrated in a few cases; but in the great majority no such evidence could be found. There seems to be a close connection between the formation of calculi in the salivary glands and the formation of calculus upon the teeth, as persons with saHvary cal- culi of the glands usually have considerable calcareous deposits upon the teeth. Richet first called attention to this fact. It has been the general impression among English surgeons that these deposits in the salivary glands were closely connected with the gouty diathesis. It has been generally stated that these calculi were composed prin- cipally of calcium carbonate and phosphate, and magnesium phosphate. Fiitterer has examined several specimens, and finds calcium phosphate largely in excess of the carbonate. Garretson reports the examination of a calculus taken from the duct of Wharton, which showed the same composition. Ptyalin, xanthin, and uric acid were also found in them by Fiitterer, which would seem to prove the connection of the forma- tion of these concretions with the gouty diathesis. The specific gravity of the calculi in the reported cases varies so greatly that no reliance can be placed upon the result of this part of the examination, from the fact that some were weighed in the dry, and others in the fresh state. Sec- tions of the calculi all show a lamellar arrangement, beginning at the center, which indicates the manner of their increase in size. These calculi form very slowly; perhaps years elapse before their presence gives rise to any serious complications. Symptoms.- — The symptoms are acute inflammation, accompanied by extensive swelling in the floor of the mouth, at the side of and 374 SURGERY OF THE FACE, MOUTH, AND JAWS. beneath the tongue. This organ is sometimes lifted up and pushed back into the fauces. Fullness of the submaxillary triangle of the neck is also observed. The pain is frequently very severe. The con- stitutional symptoms are elevation of temperature, nausea, dizziness, and a general feeling of prostration. Upon an examination of the swelling by palpation, the index finger of one hand within the mouth, over the swelling, and the other upon the neck beneath the gland, the form of the swollen gland and duct may be readily outlined. Occasion- ally the calculus can be found as a hard mass within the duct. This, however, would not be possible when the swelling was at all extensive, or the calculus was located within the gland. Inflammation and sup- puration are commonly associated at various intervals with the pres- ence of these formations in the gland or its duct. These calcuH are usually oblong or spindle-shaped in form. In size they have varied from one grain to two hundred and seventy, the latter being the largest recorded calculus found in a human subject. The largest calculus in measurement was six centimeters in length, and five and one-half in Fig. T33. Salivary Calculus FROM THE SuBMAxiLLAR\ I'.LAMi.u a Horse. (Reduced one-half ) width. Usuallv there is but one calculus found in the duct or the gland, but occasionally two or more are found lying together, facets having formed at the points of contact. Garretson mentions a case in which both of the ducts of Wharton were filled with small calculi. Salivary calculi are quite common in the larger animals, like the horse and the ox. The accompanying illustration (Fig. 133) is a calculus taken from the submaxillary gland of a horse; it weighed eleven and one-half ounces in the dried state, and measured six inches in length and two inches in width, having a circumference at its largest part of six inches. Although inflammation and suppuration are commonly recur- ring conditions, an external fistula as a result is an exceedingly rare oc- currence. Fistula following operation through the external tissues has occasionally occurred, and it is somewhat difficult to heal. Relapses after complete removal of the calculi are very rare, and it is more than likely that in most of those cases reported as relapsing, all of the cal- culi were not removed at the first operation. Diagnosis. — The diagnosis is usually a simple matter. If the duct is still patulous, a small probe — preferably made of untempered steel, mSEASES OF THE SAI.IVAKY GLANDS. 375 as this metal conducts sound, and the vibrations produced by contact are much better than the ordinary silver probe — may be passed into it until it reaches the calculus, which will be distinguished by the rough, grating sensation imparted to the fingers upon bringing the probe in contact with the stone. If the duct is not open, an exploring needle may be thrust into the swelling at various points, when if a calculus is present it will most likely be found. Cases with extensive swelling of a chronic character have been mistaken for malignant growths. The difficulty in diagnosis is much greater when the calculus is situated in the gland than when located in the duct. Treatment.- — The usual method employed for removing a salivary calculus from either of the glands or their ducts is by an incision made within the mouth over the point at which the calculus lies imbedded, or by dilating the orifice of the duct, and expressing the calculus from its bed; or by lifting it out with the forceps. Occasionally the swelling will be so great that none of these methods will avail, and this is especi- ally true of those cases in which the calculus is lodged within the gland. Futterer reports a case of this character which was seen by the writer in consultation, in which two calculi (Fig. 134) were found imbedded Fig. 134. Salivary Calculus from the Submaxillary Gland. (After Fiitterer.) in the submaxillary gland, one of which weighed one grain, and the other twenty-three grains. In this case there was extensive suppura- tion and great swelling which had lasted for several days. The pres- ence of the calculi was demonstrated by passing a fine probe into the duct of Wharton. After making an extensive incision down to the cal- culi, and repeated unsuccessful trials to grasp and remove them, the efifort was abandoned, and the wound packed with gauze. On the next day the packing was removed, which was followed by a profuse dis- charge of pus. The calculi were then easily grasped and removed with a pair of long slender forceps. Operations through the external tissues for the removal of calculi are to be deprecated, on account of the dangers of forming salivary fistula2. The after-treatment in these cases is simple. Thorough clean- liness of the mouth and wound, maintained by the use of antiseptic solutions, is all that is required. Salivary Fistulae. — Salivary fistula is a rare, but nevertheless a very troublesome affection. It is usually associated with the duct of 376 SURGERY OF THE FACE, MOUTH, AND JAWS. the parotid gland, and is very rarely met with in the submaxillary or the sublingual glands. Causes. — It may be caused by traumatic or surgical injuries, or by inflammatory conditions resulting in abscess, or by ulceration. Lacer- ated and gunshot wounds of the cheek, and surgical operations requir- ing incisions of the cheek, are the most frequent causes of the affection. The inflammatory conditions which may result in fistulae of the parotid gland are suppurative parotitis, suppurative inflammation from injury and the presence of calculi, ulceration following mercurial ptyalism, and gangrenous stomatitis. Fistula of the parotid gland has some- times occurred as the result of operations upon this organ for the re- moval of tumors. Diagnosis. — The affection consists of an outward opening of the duct of Stenson upon the external surface of the cheek, through which the saliva flows over the cheek instead of into the mouth. During the stimulation of the gland induced by the act of mastication or the odors of appetizing foods, the saliva pours out over the cheek, and be- comes very annoying. Sometimes the cheek is excoriated by the fluid, and unhealthy looking granulations spring up about the orifice of the fistula. Treatment. — A variety of operations have been proposed for the cure of this affection. They all have the same end in view, namely : to re-establish the flow of saliva into the mouth, and to close the fistula upon the external surface of the cheek. A common method of treat- ment is by cauterization and compression of the fistula. This form of treatment may occasionally succeed in those cases in which the natural orifice in the mouth still remains patulous. In the greater number of cases, however, the orifice in the mouth has been obliterated and calls for an operation to re-establish it. Agnew's method consists of passing a curved needle, armed with silk thread, around the duct, posteriorly to the fistula, from within the mouth. The needle should be entered and emerged at as nearly as possible the same point, care being taken to include the duct, but not the skin, within the loop. The thread is then to be tightly knotted, and the ends cut off. The effect of this operation is to produce ulceration within the cheek, while the ligature cutting its way through the con- fined tissue, separates after a few days, and leaves a new and artificial duct through which the saliva may find a free passage into the mouth. If the external fistula does not close immediately, the edges may be pared and brought together with sutures, and covered with a collodion dressing. Deguise's method consists of first making a puncture through the fistulous opening in the cheek obliquely backward to the inner sur- face of the cheek, and passing one end of a leaden wire through it. DISEASES OF THE SALIVARY GLANDS. 377 Second, through the same opening another puncture is made, which is directed obliquely forward, and through which the other end of the wire is passed. The -ends of the wire are then brought together and tied. The loop passing through the fistula conducts the saliva into the mouth, and the fistula closes in a few days. If it does not, it should be closed by the method just described. Van Buren succeeded in closing a salivary fistula, the result of a gunshot wound, by transferring the fistulous orifice from the outer to the inner surface of the cheek. This may be accomplished by first pass- ing a fine silver wire through the skin at opposite points on the edge of the fistulous orifice. The next step in the operation is to loosen the fistulous orifice and the duct from the surrounding tissue, for the dis- tance of about half an inch backward, then make an incision through the wound to the inner side of the cheek, drawing the fistulous orifice through it, and retaining it in its new position by means of the wire. The external opening is to be closed with silver wire sutures. The wound should be treated antiseptically. REVIEW. CHAPTER XXXVII. What terms are applied to inflammation of the parotid gland? What is parotitis? In what forms does the disease appear? What character does the disease sometimes assume? What are the symptoms of the disease? How does the milder form differ from this? Does it afifect the glands simultaneously? Is immunity obtained by a single attack? Is the pathology known? What are the chief dangers of the disease? In about what per cent, does metastatis occur in the testes? What is the usual duration of the disease? How does it generally terminate? With what other diseases is parotitis sometimes associated? Does lymphatic involvement take place? What are the constitutional conditions in this form of the disease? What is the character of the pus? Give the prognosis. In what directions may the pus burrow? How should the milder cases be treated? What should be the treatment in the common form? What should be the treatment in the severer form? 378 SURGERY OF THE FACE, MOUTH, AND JAWS. Where should the line of incision be made in operating upon suppurating glands? How should the constitutional condition be treated? What are salivary calculi? Are they common or rare? In which glands are they most frequently found? What do Futterer's statistics prove? At vifhat period of life do salivary calculi most frequently occur? What was the age of the youngest case found by Fiitterer? What was the age of the oldest? What was the age in Burdel's case? How is the presence of a calculus in so young a child explained? What are the causes of the disease? With what local and constitutional conditions are these formations closely connected? What is the composition of salivary calculi? What is the appearance on section? Do such calculi form rapidly or slowly? Describe the symptoms. What is the usual shape of these calculi? What are the variations in weight? What are the measurements of the largest calculus removed from the human subject? Do they occur singly, or how? Are they found in animals? Is external fistula common? Do relapses occur? How may the diagnosis be made? In what kind of cases is the diagnosis most difficult? How may the calculi be removed? What is the after-treatment? Is salivary fistula a rare affection? With which glands is it most commonly associated? What are its causes? What are considered as the most frequent causes? What are the inflammatory conditions occurring in this gland which may result in fistula? Describe the appearance of salivary fistula. What condition is caused by the flowing of the secretion over the cheek? What are the main objects of an operation? Describe Agnew's operation for the cure of salivary fistula. What is the effect of this method of operation? How should the external fistula be closed? Describe Deguise's operation. How did Van Buren succeed in closing a salivary fistula resulting from a gunshot wound? CHAPTER XXXVIII. NEURALGIA, Definition. — Neuralgia (Greek i-so/j'/v, nerve; a/.y.ii, pain). Neuralgia is a severe parox3"smal pain in the area of distribution of a nerve, or along its course. It has become customary to designate all pains which occur in paroxysms, unattended with local or general elevation of temperature, and distributed along the course of nerve-trunks or nerve-branches, for which no adequate cause can be assigned, as neuralgia. (Putnam.) Neuralgia is not a disease, nor a morbid condition, in the sense of its having an individitality, but is a phenomenon, or an expression of a disease or of a morbid general or local condition. Neuralgia has been called "the prayer of the nerves for blood," and "the cry of the hungry nerves for food," but these suggestions as to the etiology of neuralgia do not cover all the causes which produce this most distress- ing and painful phenomenon. Neuralgia is a medical rather than a surgical affection, and rarely comes imder the observation of the surgeon except as the result of injury, or the implication of the nerves in the healing of wounds or cicatrices, or when medical treatment has failed to relieve the pain and surgical operation is sought as a last resource. The conditions which are productive of neuralgia are many and varied, and consist chiefly of diseases which lower the vital powers of the system, such as anemia, or those which interfere with such func- tions as the circulation, respiration, digestion, assimilation, secretion, and elimination; the presence in the system of abnormal substances, as in gout, rheumatism, diabetes, malaria, nephritis, chronic pyemia, syphilis, and metallic poisoning; local conditions which cause reflex peripheral irritation, such as diseases of the teeth, eyes, ears, stomach, uterus, and ovaries; chronic inflammation of the nerve or its sheath; pressure from abnormal growths within the bony canal through which the nerve-trunk passes, or pressure from tumors, and localized anemia or congestion of nerves or nerve-centers. Neuralgia may therefore be the result of an actual diseased condi- tion of the nerve, as for instance in a neuritis, or it may exist with no discernible structural change in the nerve-tissue or the nerve-centers. 379 380 SURGERY OF THE FACE, MOUTH, AND JAWS. The changes which may take place in the nerve-tissue under such conditions may be simply molecular, and these, with our present means of examination, are not capable of being demonstrated ; but the way in which certain forms of neuralgia behave, as for instance their sudden disappearance from one part to reappear in another and perhaps re- mote location, or their complete disappearance after a short period, confirms the general opinion that these forms are not due to any or- ganic change in the nerve itself. On this account it has become customary to divide all neuralgias into two distinct classes, placing those in which there are appreciable changes in the nerve-tissue under the head of symptomatic neuralgia, and all others under the head of idiopathic neuralgia. In symptomatic neuralgia the pain is dependent upon the neu- ritis or other structural changes in the nerve-tissue or its sheath, while in idiopathic neuralgia the pain does not depend upon any discoverable change or alteration in the nerve-tissue. Of the pathologic anatomy of such a condition there is absolutely nothing known. In the character of the pain in these two varieties of neuralgia, there is very little difference; but the symptoms which accompany the pain are not alike. The principal difference in the symptoms lies in the greater degree of pain manifested in a neuritis, and the sensitiveness which exists over the nerve-trunk. (Sinkler.) All neuralgias have one common tendency, which is manifested in a greater or less degree, viz: periodic recurrences, but the degree of periodicity varies greatly. These recurrences are most regular and best marked in the malarial neuralgias, and in those dependent upon neurotic conditions like migraine and the periodic headaches. Neuralgia affecting the viscera occurs with less regularity. One variety of neuralgia affecting the ophthalmic division of the trifacial nerve evinces a tendency to daily recurrences at the same hour (usually about nine a.m.) for a certain period. This is particularly marked in those cases dependent upon malarial influences, and catarrhal affec- tions of the frontal sinuses. The writer had under observation recently a case of this character which was due to catarrhal inflammation of the frontal sinuses. The pain was intense for an hour to an hour and a half, the paroxysms being from three to five minutes apart. The patient complained of a stopped-up feeling in the nasal passages and a sense of fullness in the frontal region on rising in the morning. This lasted until the paroxysms ceased, when the sense of fullness also disappeared. The patient made constant effort during the period of the paroxysm to clear the nasal passages, and he believed that as soon as this effort was successful the pain ceased. The neuralgias are also again divided according to their location and their symptomatology, into, — NEURALGIA. 38I 1. Superficial. 2. Msceral. 3. Migraine and the migrainoid headaches. The superficial variety of neuralgia is limited to the course and area of distribution of a single superficial nerve or group of nerves, like the sciatic and the trifacial. The visceral forms of neuralgia are less definitely localized by the sensations of the patient than in the superficial variety, and as these nerves are deep-seated it is difficult to indicate which are at fault. Migraine is a complex sensory neurosis characterized by pain in various locations of the cranium; the occipital region, the vertex, the frontal, or the temporal region. Causes.- — The causes of neuralgia may be divided into two forms, predisposing and exciting. The predisposing causes are, — 1. Hereditary tendencies. 2. Periods of life at which certain critical changes take place. 3. Influences associated with sex. 4. The effects of constitutional diseases, such as anemia, gout, rheumatism, phthisis, diabetes, nephritis, malaria, syphilis, and metallic poisoning. The exciting causes are, — 1. Atmospheric conditions, as indicated by a low barometer; and the local action of heat and cold. 2. Injuries and direct irritation of the nerves. 3. Indirect irritation of the nerves (reflex). 4. Acute febrile diseases. Predisposing Causes.- — Hereditary Tendencies: The fact of the in- heritance of neuralgic tendencies by certain famihes who give other signs of a neuropathic taint, is so well established that it does not admit of question. The tendency is most marked in the case of migraine, and other periodic headaches. It is also noticed in visceral neuralgias, and particularly so in facial neuralgias, though less marked in the other forms of superficial neuralgias. (Putnam.) Age: Age is an important factor in the predisposition to neural- gic afifectioris, which are most common in middle life, and at those periods which mark the growth and the decline of the sexual functions. According to Anstie, these conditions when once established are in- clined to continue into advanced age, but fortunately cases beginning at this period are relatively rare, though exceedingly intractable. Childhood and youth are usually exempt from superficial neural- gias, though migraine and periodic headaches may develop in children of neurotic temperament. These conditions may later in life give way to more serious neuroses. 382 SURGERY OF THE FACE, MOUTH, AND JAWS. Sex: Women, as a rule, are more liable to certain forms of neu- ralgia than are men. This is particularly noticeable in neuralgias of the trifacial, occipital, and intercostal nerves; while men suffer most frequently from the brachial, crural, and sciatic neuralgias. Putnam thinks this is due to the stronger neurosal element in women, and the neuritic element in men. Constitutional Diseases: Any and all constitutional disorders which by virtue of their action produce an impoverished condition of the blood or retrograde tissue-changes, or the disturbance of vital or other important functions of the body, undoubtedly predispose to neuralgia and other neurotic affections. Among these predisposing constitu- tional causes may be mentioned phthisis, anemia, gout, rheumatism, diabetes, malaria, nephritis, chronic pyemia, syphilis, indigestion, mal- assimilation, perversions in secretion and elimination, conditions of the vaso-motor system which produce local congestion or anemia, and the presence within the system of certain toxic substances such as the metallic poisons. Ehrmann has published an account of four cases in which small doses of potassium iodid produced trigeminal neuralgia. Lead, arsenic, antimony, and mercury are all capable under favor- ing circumstances of so impairing the nutrition of all nerve-tissue as to seriously predispose it to neuralgic attacks. Exciting Causes. — Atmospheric conditions, and Thermal influences: It has long been known that certain atmospheric conditions, especially those preceding a storm, were likely to excite attacks of neuralgia, and that the various forms of neuralgia were more prevalent in the cold and damp seasons of the year, in cold and damp localities, and in per- sons whose occupations compelled them to work in a cold and moist atmosphere, or who were subject to frequent and extreme changes of temperature, than under different circumstances. In a series of observations conducted by a military officer under the direction of S. Weir Mitchell, in relation to the conditions of the atmosphere preceding a storm and the coincident attacks of neuralgia in the stump of an amputated limb, from which the officer suffered most intensely, it was found that the attacks of pain were accompanied by a falling barometer, though the severity of the pain did not neces- sarily bear a proportionate increase with the rapidity or the extent of the fall. The moisture of the atmosphere seemed to have a certain effect, but the attacks occurred even when the storm center was so far removed that no local rain-fall took place. The electrical disturbances of the atmosphere could not be studied with accuracy, but there seemed to be a certain relationship between the attacks of pain and the appear- ance of the aurora boreaHs. (Putnam.) Injuries and Direct Irritation of the Nerves. — Among the principal exciting causes of this class may be named wounds and injuries to NEURALGIA. 383 the nerves; impingement of nerves within cicatricial tissue; pressure from neoplasms and certain inflammatory swellings (gumma, etc.); narrowing of the bony canals and foramina, and aneurisms. Fig. 135. Malposition of the Right Ramus, the Result of Partial Exsection of the Jaw for Sarcoma, which caused Persistent Temporo-Maxillary Neuralgia. Fig. 136. Result, One Year after Operation. Teeth were Lost by reason of Pyorrhb Alyeolaris. The writer reported a case at the Ninth International Medical Congress, of persistent neuralgia of the temporo-maxillary articulation of eight years' standing, which was due to the malposition of the right ramus, caused by exsection of a portion of the jaw, — from the angle to the first bicuspid tooth, — and contraction of the cicatricial tissue, which 384 SURGERY OF THE FACE, MOUTH, AND JAWS. was entirely cured by an operation which replaced the ramus in its nor- mal position and thereby relieved the tension upon the articular liga- ments of the joint. The case has already been referred to in another chapter as an example of bone-grafting. Fig. 135 is an illustration of the position of the ramus before the operation, and Fig. 136 shows it one year after the operation, the teeth having been lost by pyorrhea alveolaris. Indirect Irritation of the Nerves. — Under this class of exciting causes are grouped all those disorders which produce these effects through reflex or sympathetic action. As an illustration, diseases of the uterus and ovaries not infrequently cause reflex facial, mammary, intercostal, and gastric neuralgia. The writer for several years had under observation a sufiferer from dyspepsia accompanied by severe gastralgia and reflected neuralgic paroxysms in the left brachial plexus. The reflected pain was always in the same location, and often of so severe a type as to greatly interfere with the use of the arm upon the following day on account of the soreness of the muscles. The eye is an important center of nervous irritation, and errors of refraction, even when quite slight, are sometimes productive of mig- raine. Inflammatory conditions of an acute and chronic nature affect- ing the maxillary and frontal sinuses are also productive of neuralgic attacks. Acute Febrile Diseases. — Acute fevers -are occasionally the exciting cause of neuralgia. Thus, Nothnagel describes neuralgias which came on during the first week of typhoid fevers. Putnam mentions a case which came under his own observation, in which "a severe facial neu- ralgia appeared during the first week of an insidious attack of pneu- monia in an individual who was not of neuralgic habit, and before the fever or inflammation had become at all severe." It is possible that other acute affections may have a similar effect. Trifacial Neuralgia.' — From the surgical standpoint the super- ficial forms of neuralgia are the only varieties of especial interest to the surgeon, as these only are amenable to treatment by surgical proced- ures. Neuralgia of the trifacial and sciatic nerves, the brachial plexus, and the neuralgia of stumps and scars, are the most common forms of the superficial affection. Neuralgia of the trifacial nerve (tic douloureux) is the form which most frequentlv comes under the observation of the dentist and the oral surgeon. Trifacial or trigeminal neuralgia appears in two forms, viz: acute and chronic. The acute form of the affection is frequently associated with or de- pendent upon acute inflammatory conditions of the teeth and alveolar NEURALGIA. 385 processes, acute affections of the eye and ear, and of the maxillary and frontal sinuses. This form of neuralgia is usually of short duration, and generally disappears upon the subsidence or the removal of the exciting cause. The chronic form is often persistent in its character; the exciting cause difficult to find ; and the affection does not always disappear upon the removal of the supposed cause on account of the structural changes which may have taken place in the nerve-tissue or the sheath of the affected branches or of their blood-vessels. It not infrequently hap- pens that more than one abnormal local or constitutional factor may be involved in the causation of tlie various forms of neuralgia; failure in one direction should therefore lead to renewed search in some other, with the hope of finally discovering the other factors in the case, and removing them if possible. Neuralgia may exist in any of the nerves as a result of neuritis, but it is most frequently observed in the sciatic and trifacial nerves. The frequency with which the various branches of the trifacial nerve are the seat of neuralgia may be stated to occur in the following- order: the superior maxillary division, the inferior maxillary division, and lastly, the ophthalmic division. In neuralgia of the superior maxillary division, the pain is some- times located in the dental branches, being referred to the upper teeth, guins, and maxillary bone; at other times it affects the infraorbital branch, the pain being referred to the integument of the cheek, the side of the nose, and the upper lip. Infraorbital neuralgia is frequently associated with neuralgia of one of the other branches of the fifth nerve, usually with the first division. When affecting the inferior division, the pain is most frequently located in the lower teeth, the gums, and the integument of the lower lip and the chin. When located in the ophthalmic division it most often affects the supraorbital branch, the pain spreading out over the forehead, the eyebrow, and the upper eyelid. It is a common occurrence for the patient to refer the pain in the beginning of a paroxysm to the point of exit of the nerve from its bony canal, for instance at the infraorbital, mental, and supraorbital foramina. Symptoms. — Neuralgia of the fifth nerve rarely appears until after middle life, and in old persons it frequently resists the most intelligent treatment. The fact that the affection does not appear as a rule until after middle life, when the senile changes are beginning to take place, would seem to indicate a connection between these changes and the appearance of this form of neuralgia. The pain is of the most excruciating character. There is no other 26 386 SURGERY OF THE FACE, MOUTH, AND JAWS. disease, with possibl}' the exception of tetanus, which from the severity of the suffering is so calculated to arouse the sympathies and com- miseration of the surgeon and those in attendance upon the case, as the severe forms of tic douloureux. In tic douloureux, or "epileptiform neuralgia," as Trousseau termed it, the pain comes on suddenly, sometimes preceded as in epi- lepsy by an aura. The character of the pain is acute, occurring in dis- tinct paroxysms, with longer or shorter intervals, sharp, stinging, or lancinating, gradually increasing in intensity for a few moments, until it reaches a climax, and as graduall)' and quickly subsiding, to be again followed by another paroxysm of equal degree of intensity. The pain is so fearfully severe in some cases as to cause the patient to moan or cry aloud with every paroxysm, and after the paroxysm is past to sit in terror waiting the onset of the next attack. This may continue for hours without cessation, or the paroxysms may last but for an hour or two, the remainder of the daj- being quite free from pain; or it may be excited at any time by talking, laughing, mastication, or even passive movements of the muscles of mastication, speech, or expression. A slight noise or a light touch may precipitate a paroxysm. In some cases the patient will be entirely free from pain during the night, but upon awakening in the morning the slightest movement of the muscles of the face precipitates the paroxysms of pain. Occa- sionally the pain will be severe during the night, and the patient com- paratively free during the day, and able to go about his daily vocation ; while in others the pain may be induced at any time by the movement of the muscles, so that the question of taking food becomes for several days at a time one of great dread; in fact, patients frequently abstain from the taking of aliment except in a liquid form for days together. The pain and the dread of the returning paroxysms make life a burden. Besides the pain, other symptoms of lesser note occur in facial neuralgia. Increased secretion of the lachrymal, salivary, and mucous glands is a frequent occurrence. The hair of the face or side of the head becomes dry and brittle, and is inclined to fall out, or it may lose its color rapidly, regaining it after the attack has passed. (Putnam.) There is increased secretion of urine. Anstie noticed unilateral furring of the tongue. The muscles to which the pain is referred may some- times become paretic. Temporary amaurosis, and sometimes loss of the eye of the affected side, may take place in tic douloureux. The senses of hearing, taste, and smell may likewise be temporarily lost. Causes. — Among the more common exciting causes of trifacial neuralgia expressed in the various divisions of the fifth nerve, may be mentioned the following conditions: In the ophthalmic division in- flammatory affections of the conjunctivae, diseases of the globe of the eve and iritis, and catarrhal conditions of the frontal sinuses. In the NEURALGIA. 387 superior and inferior maxillary divisions, inflammatory conditions of the teeth and jaws, particularly pulpitis, pericementitis, and periostitis Fir,. 137. Inferior Molar — Vertical Section. Showing Pulp-nodule (enlarged). of the alveolar processes; structural changes in the teeth, like inter- stitial calcification of the pulp, pulp-nodules, and exostosis of the root. 3ob SURGERY OF THE FACE, MOUTH, AND JAWS. Fig. 137 is from a case of neuralgia of the third division of the trifacial nerve induced by the formation of a pulp-nodule. Difficult erup- tion of the teeth, particularly of the lower third molars; exposed sensi- tive dentine from caries, abrasions, or fractures which have caused a loss of the enamel; and lastly, inflammatory and other diseased condi- tions of the maxillary sinuses, which are particularly associated with neuralgia of the superior maxillary division. Syphilitic manifestations of a secondary and tertiary nature may produce inflammatory infiltration of the nerve-sheath, or neuritis, and cause neuralgia in either or all of the branches of the fifth nerve. Osseous growths within the bon}^ canals or the foramina through which these nerves pass is not an infrequent exciting cause of neural- gia. These growths may be in the form of tubercles arising from the walls of the canals, or in the form of a diffuse exostosis; in either case a narrowing of the canal or its foramen is the result, pressure upon the nerve is induced, and as the patient grows older there is caused a pro- gressive neuralgia. The various forms of irritation, both direct and indirect, not infre- quently set up a neuritis in the various branches of the nerve, as dem- onstrated by Putnam and others. Dana found striking evidences of arterial disease in three cases of typical trifacial neuralgia, but no note- worthy changes in the nerves. He believes the cause of neuralgia to be obliterating arteritis, and gives as his reasons for this opinion that "the disease occm-s at an age when degenerative changes begin in the arteries and follow a certain fixed distribution." Tuffier found positive evidence of neuritis in one case examined by him of neuralgia of the inferior maxillarjr nerve. In this case the nerve was "swollen and reddened both within the dental canal and before its entrance." Sinkler also found like evidences of neuritis in a case of neuralgia of the inferior maxillary nerve. Diagnosis. — The manifestations of trifacial neuralgia are so char- acteristic that an error in the diagnosis could hardly be made. Valliex discovered certain points of tenderness in cases of facial neuralgia which are designated as "points douleureux." These are located in the ophthalmic division, at the supraorbital foramen, on the upper eyelid, at the line of union of the nasal bone with the cartilage, at the inner angle of the orbit, and in the eyeball itself. Another point is near the parietal eminence. In the superior maxillary branch the painful points are situated at the infraorbital foramen ; at a point over the most prominent part of the malar bone ; an uncertain point on the gum of the superior maxilla ; a similar point upon the upper lip, and another upon the palate. In the inferior maxillary division the painful points are found over the auriculo-temporal branch just in front of the ear; another over the NEURALGIA. 389 inferior dental foramen, and still another over the mental foramen. The presence or absence of these "points douleureux" are not positive diao'nostic signs, though as a general rule tenderness will be found over the foramina named. REVIEW. CHAPTER XXXVIII. Give the definition of neuralgia. What forms of pain are termed neuralgia? Is neuralgia a disease? What has this plienomenon been called? Is neuralgia a medical or surgical affection? What are some of the principal conditions that are productive of neuralgia? What changes may some of these conditions produce in the nerve? Is it possible to demonstrate the molecular changes that may take place m the nerves? What peculiar phenomena in the history of neuralgia would seem to indi- cate that the affection was not always due to changes in the nerve-tissue? What is the difference between symptomatic and idiopathic neuralgia? To what is the pain in symptomatic neuralgia due? What does the pain depend upon in idiopathic neuralgia? Are there any known pathologic changes in the nerve in idiopathic neu- ralgia? What are the dift'erences between these varieties of neuralgia in the char- acter of the pain and symptoms? What common tendency belongs to all neuralgias? In what forms of neuralgia are these periodic recurrences most marked? Do visceral neuralgias recur with the same regularity? What forms of neuralgia sometimes have daily recurrences at the same hour? What is the character and duration of the pain in these cases? Upon what other basis may neuralgias be divided? Name these forms. Describe the superficial variety. How does the visceral form differ from the superficial? What is migraine? How may the causes of neuralgia be divided? Name the predisposing causes. Name the exciting causes. In what forms of neuralgia are the hereditary forms most marked? How does age affect the different forms of neuralgia? At what period of life is neuralgia most common? What period of life is most exempt from neuralgia? How does sex influence the predisposition to neuralgia? How are these tendencies accounted for? 390 SURGERY OF THE FACE, MOUTH, AND JAWS. How do constitutional tendencies predispose to neuralgia? Name some of the constitutional conditions which predispose to neuralgia. Name some of the toxic substances that may be productive of neuralgia. What are the atmospheric and thermal conditions which excite attacks of neuralgia? What are the forms of injury and direct irritation that cause neuralgia? What class of disorders produce neuralgia by indirect irritation? What forms of acute febrile disease have been known to produce neuralgia? What are the most common forms of superficial neuralgia? What other term is applied to trifacial neuralgia? In what forms does trifacial neuralgia appear? What are the causes of the acute form of neuralgia? What is the character of its course? What is the character of the chronic form? Is it possible that more than one abnormal factor may be present in the causation of chronic neuralgia? In what superficial nerves is neuritis most frequently observed? In which branches of the trifacial nerve is neuralgia most commonly ob- served? Where is the pain located in the superior maxillary division? Neuralgia of what other division may be associated with neuralgia of the infraorbital? Where is the pain most frequently located when the inferior maxillary division is affected? What is the location of the pain in neuralgia of the ophthalmic division? To what point does the patient usually refer the pain at the beginning of a paroxysm? At what period of life does neuralgia of the fifth nerve usually appear? What would this seem to indicate as a cause of the affection? What is the character of the pain? By what condition is the pain sometimes preceded? Describe a neuralgic paroxysm. What are some of the conditions which excite the paroxysms? What are some of the exciting causes of neuralgia of the ophthalmic division? Name some of the more common exciting causes of the superior maxillary division. How may syphilis become an exciting cause? How may osseous growths produce neuralgia? What sometimes results from direct and indirect irritation to a nerve? Has neuritis been demonstrated in trifacial neuralgia? To what does Dana think neuralgia may be due? Is the diagnosis of trifacial neuralgia difficult? Name Valliex's "points douleureux" of the ophthalmic division. Where are they located in the superior maxillary division? What is their location in the inferior division? CHAPTER XXXIX. TREATMENT OF TRIFACIAL NEURALGIA. Trifacial neuralgia is sometimes amenable to treatment by cer- tain drugs. Their therapeutic effect is, however, often very disappoint- ing, and one after another may be tried with little or perhaps no benefit. Success in the direction of treatment by drugs will depend upon the age and the general condition of the patient, and the causative agents which are responsible for the affection. It must be regarded, how- ever, as one of the most intractable of diseases. The long list of remedies which have been recommended from time to time attest the difficulties that are met with in attempts to eradicate the disease. It is especially necessary in the treatment of facial neuralgia to look beyond the relief of the particular attack under observation and search for the cause or causes which have provoked the attack. These conditions have already been referred to, and should receive that treatment which is appropriate to the individual ailment. It may be assumed, however, that in a majority of the cases of protracted neuralgia, neuritis is present, and this condition should re- ceive appropriate treatment by local applications and galvanism. As many cases of trifacial neuralgia are due to the impairment of the general health, remedies which are directed to the building-up of the system are sometimes successful in curing the affection. Quinin, arsenic, and iron have been found useful in this direction; the precipitated subcarbonate of iron administered in large doses has been found exceedingly beneficial. Gclsemium has been found by many authorities to be one of the most potent remedies in the treat- ment of neuralgias of the fifth nerve. It gives its best results, how- ever, in those cases which are dependent upon diseased conditions of the teeth. Sinkler has found it useful in neuralgia of all the branches of the fifth nerve. The writer has had a like experience in most of the cases in which it has had a fair trial. In one case, however, recently tmder his care, this drug at first gave complete relief administered in the form of sulfate gclseminine, gr. 1-30 every two hours until the con- stitutional effect was produced. In the next attack, which came on seven days afterward, it had no appreciable effect when carried to the point of drooping eyelids and dimness of vision. The fluid extract is 391 392 SURGERY OF THE FACE, MOUTH, AND JAWS. generally considered the best preparation, but because of its unrelia- bility in strength the writer prefers the sulfate gelseminine. Valerianate of zinc was at one time highly recommended, but it is not at the present time held in much esteem. Cannabis indica is a remedy of value in some cases. To obtain the best results it should be given in full doses, and repeated as often as the patient can tolerate. Seguin and others have highly recommended the use of aconite. This drug, to be of value, should be administered until numbness and tingling are felt in the lips and face. It should, however, be adminis- tered with great caution. Its value no doubt lies in its power to dimin- ish arterial tension. Belladonna, though highly recommended, does not appear to re- ceive the confidence of the profession as a valuable remedy in this connection. Thompson has recommended phosphorus in large doses for its curative effects. Gowers reports a case that was entirely relieved by a three months' treatment with phosphorus. Others, however, have not succeeded in obtaining the same results. It has the objection of being irritating to the stomach. Cimicifiiga combined with cannabis indica has been extolled as valuable in those cases dependent upon or connected with rheumatism. Ringer, Hare, and others have highl}' recommended croton chloral — butyl chloral — in the treatment of tic douloureux. Hare administers it in five-grain doses every two hours, and finds that its influence is not only palliative but curative. Antipyrin, phcnacetin, and salol have all been recommended as valuable agents, particularly in the rheumatic forms of the afifection. Opium has no curative value, but it is often necessary to adminis- ter morphin hypodermically to control the severe paroxysms of pain. Cocain is sometimes administered in the same manner, and for the same purpose. In cases presenting a syphilitic histor\', iodid of potassium in twenty-grain doses, increased to thirty or forty grains three times per day, has sometimes proved curative. Electricity, when judiciously applied, is of great value. The gal- vanic current is the most beneficial. Authorities differ as to which pole should be applied to the painful spot. Sinkler recommends the negative pole. Gowers thinks the direction of the current is of no great importance. The writer uses the positive pole at the painful spot, and a current of from one to three milliamperes. The current may be applied for from two to five minutes. As local applications, menthol and the oil of peppermint often afford temporary relief. TREATMENT OF TRIFACIAL NEURALGIA. 393 Surgical Treatment. — Various surgical operations have been recommended for the rehef of superficial neuralgia. These opera- tions are, subcutaneous division of the trunk of the nerve, resection of the trunk of the nerve, nerve-stretching, evulsion, and the tying of arteries leading to nerve-trunks and nerve-centers. Subcutaneous division of nerves is productive of immediate relief from the pain for a short time, but eventually, after a few weeks or months, the pain returns as a result of the reunion of the divided nerve. Excision gives somewhat better results, in that the interval be- tween the operation and the return of the pain is much longer; usually there is complete relief for six or seven months and occasionally for two or three years. As a rule, the more extensive the piece removed, the longer will relief be afforded. It is customary to remove at least half an inch, and as an added safeguard against reunion, to bend back the peripheral end of the segment upon itself. Nerve-stretching has been followed by complete relief for a time, but so far the reports upon this method do not seem to indicate any better results than are obtained by simple section of the nerve. Andrews reports a case in which stretching of the stump and tearing away of the cicatrix in a case of neuralgia of the inferior maxillary division upon which he had operated one and a half years before by excision with complete relief, but in which the pain had again become severe, was completely successful in abating the trouble. Evulsion is sometimes productive of better results than excision, as man}' times a longer section of the nerve can be removed than by cutting it with a knife or neurotome. This method consists of grasp- ing the nerve — after it has been separated from its vessels — as far back as possible, with hemostatic forceps, and forcibly tearing it away. Subcutaneous Division of the Supraorbital Nerve is accomplished Ijy entering a tenotome knife between the eyebrows midway between the nerve and the median line, and passing horizontally beneath the skin until its point is beyond the nerve; its edge is then turned back- ward and pressed against the bone, and the nerve, lying between it and the bone, is divided by withdrawing the knife. Or, the knife may be entered at the same point, but passed close to the bone instead of just under the skin, its edge turned downward toward the margin of the orbit, and the nerve divided by sweeping the knife downward across the mouth of the supraorbital foramen. (Stimson.) Excision of tJw Supraorbital Nerve may be made through incisions above or below the eyebrow. When made above, the incision may be an inch long and parallel to the eyebrow, with its center directly over the supraorbital notch or foramen. (Fig. 138, A.) The incision is carried down to the bone, the distal end of the nerve seized with for- ceps, dissected out, and excised. 394 SURGERY OF THE FACE, MOUTH, AND JAWS. The incision made below the eyebrow requires the eyebrow to be drawn up, and the eyehd down, so as to make the tissues tense. An incision is then made close to the lower edge of the supraorbital arch, an inch long, through the skin, orbicularis muscle, and tarsal ligament. (Fig. 138, B.) The nerve is then traced backward from the notch as far as necessary by depressing the eyeball and the levator palpebrse with a spatula, and dividing the nerve with curved scissors. Excision of the Superior Maxillary Nerve is made by a curved in- cision about an inch and a half long following the lower border of the orbit; a second incision at right angles to the first, one inch in length, is next made upon a line drawn from the supraorbital notch to the mental foramen, which will intersect the infraorbital foramen and Fig. 138. A, B, Incisions for Excision of the Supraorbital Nerve ; C. Incision for Excision of tire Infraorbital Nerve, after the method of Tillaux. expose the nerve. (Fig. 138, C.) A silk thread is now passed beneath the nerve and tied for the purposes of identification and traction. The orbital tissues are then lifted by dissecting up the periosteum from the floor of the orbit, and elevated with a spatula; the infraorbital canal found and broken through, the nerve isolated and lifted from its bed with a curved hook, and divided with curved scissors at a point as far back in the orbit as possible. Traction upon the ligature will draw the nerve from its canal, when it may be severed below the ligature. Hem- orrhage is rarely troublesome, though occasionally it may be necessary to use a little packing to control the hemorrhage within the orbit. Fig. 139 shows scar resulting from two different operations for infraorbital neuralgia; A, Liicke's operation; B, Tillaux's operation. Removal of Meckel's Ganglion.- — This operation is sometimes un- dertaken after the removal of the superior maxillary nerve. This is done by an operation devised by Carnochan, which consists of a T- TREATMENT OF TRIFACIAL NEURALGIA. 395 shaped incision below tlie orbit, the horizontal line reaching from can- thus to canthus, and the vertical one nearly to the mouth; the tissues are dissected from the facial surface of the bone, and the infraorbital nerve found and secured with a ligature. The outer wall of the antrum is next perforated with trephine or chisel, the infraorbital foramen Fig. 139. A, Incision for Lii -operalion. i operation for Ex of the Infraorbital Nerve being included. The posterior wall of the antrum is also perforated in the same manner, care being taken not to wound the internal maxillary artery, which lies immediately behind and in close relation to the bone. The groove in the floor of the orbit is next broken through, and after dividing the nerve upon the cheek it is drawn down and through the perforation in the posterior wall of the antrum. Tension upon the 396 SURGERY OF THE FACE, MOUTH, AND JAWS. nerve offers a sure guide to the ganglion, by tracing it back into the spheno-maxillary fossa, and to the foramen rotundum, where it may be divided by long, slender, curved scissors. Hemorrhage may be controlled with gauze or sponges fastened to sponge-holders. For the purpose of illuminating the deeper portions of the wound an electric light or a head mirror are absolutely necessary. Excision of the Inferior Maxillary Nerve. — This nerve may be divided in three locations, at its exit from the mental foramen, in the canal, and before its entrance into the canal. Fig. 140. A, Garretson operation A B. Agnew operation ; C, Pancoast operatii (After Cryer.) D, Cryer operatii Excision at the Mental Foramen. — This is accomplished within the mouth by an incision in the gingivo-labial fold above the foramen, which is located just behind the root of the first bicuspid tooth. The soft parts are dissected from the bone with an elevator or periosteo- tome, until the nerve is reached, which is usually about an inch or an inch and a quarter below the tip of the cuspid tooth. The nerve may then be seized with forceps and drawn as far from the canal as possible, and divided with scissors close to the bone, and upon the peripheral side close to the soft tissues. Excision zvithin the Canal. — This can be most successfully made by the Garretson operation (Fig. 140, A), which consists of making an in- TREATMENT OF TRIFACIAL NEURALGIA. 397 cision about two inches long from the angle of the jaw forward. The incision should, for cosmetic reasons, be kept well under the lower bor- der of the jaw. This incision will divide the facial artery, which must be secured. The tissues are now lifted from the outer surface of the bone by a periosteotome, for the entire length of the incision. The ex- ternal plate of the jaw is next trephined at the opposite ends of the in- cision, and about a quarter of an inch above the lower border of the jaw; the perforations made by the trephine are next vmited by two parallel incisions in the bone by a small circular saw, revolved by the surgical engine, — the trephine is driven by the same power, — -when with an elevator the section of bone can be lifted from its place, thus exposing the inferior dental nerve and vessels lying in the canal. The nerve is then isolated and lifted from its bed with a blunt hook, and a section removed. Care should be taken not to wound the artery, as hemorrhage is sometimes troublesome. Agnew's operation consists of trephining the jaw at the angle directly over the canal (Fig. 140, B), and removing a section of the nerve. Fig. 141. Mason Gag. Excision before its entry into the canal may be made either through the mouth or through the cheek. In operating through the mouth, the jaws must be extended as far as possible with a mouth-gag placed upon the opposite side (Fig. 141). The mucous membrane is first incised at a point on the anterior border of the ascending ramus, midway between the crowns of the upper and lower second or third molar teeth, while the jaws are in this extended position. The finger is next inserted between the internal pterygoid muscle and the ramus. The tubercle situated at the opening of the foramen is now felt (Fig. 142, S), and the nerve brought to the surface by means of a blunt hook, grasped with hemostatic forceps, and a section removed. Hemorrhage is sometimes profuse. Care must be exercised not to mistake the long internal lateral ligament for the nerve. Pancoast performed excision of the nerve by first removing the coronoid process by an incision through the cheek (Fig. 140, C). There is a serious objection to this operation, for the reason that it destroys the use of the temporal muscle. 398 SURGERY OF THE FACE, MOUTH, AND JAWS. In operating through the cheek by an external incision, after the method of Cryer, an incision is made over the center of the ramus, beginning at the zygomatic arch and extending downward an inch and a half; the semilunar notch is now exposed and deepened with surgi- cal burs to the depth of about one inch, when the opening thus made Fig. 142. Inferior Max Bone — Internal Surface of the Right Side. G, Genialtubercles ; M, Mylo-hyoid ridge ; O, Opening of the inferior dental canal ; H, Mylo-hyoid groove ; S, Pterygoid tubercle ; A, Anterior or coronoid process ; P, Posterior or condyloid process. through the bone exposes the nerve. (Fig. 140, D.) - It is now picked up and a section removed. The wounds are to be sutured, and if treated with antiseptic precautions, will commonly unite by first inten- tion. REVIEW. CHAPTER XXXIX. The systemic treatment of neuralgia depends upon what conditions? Does the affection respond to drugs? What general conditions should be sought for? On what affection may it be a.ssumed that the majority of cases of facial neuralgia depend? What should be the treatment of those cases dependent upon the impair- ment of the general health? What remedies are usually prescribed in such cases? What is the value of gelsemium in trifacial neuralgia? TREATMENT OF TRIFACIAL NEURALGIA. 399 In what form of the drug and in what doses may it be administered? What is the vahie of valerianate of zinc? How is cannabis indica administered to obtain the best results? How should aconite be administered, and how does it produce its effect? Is belladonna useful in the treatment of this afifection? What are the opinions in regard to the use of phosphorus in this affection? In what form of neuralgia is cimicifuga combined with cannabis indica recommended? What are the opinions as to the value of croton chloral in the treatment of neuralgia? In what doses may it be administered? In what forms of neuralgia are antipyrin, phenacetin, and salol recom- mended? For what purpose are opium and morphia used in neuralgia? How may cocain be beneficially used? In what cases is the iodid of potassium recommended? What is the value of electricity, and which current gives the best results? What strength of current is most beneficial? What local applications may sometimes afford relief? What operations have been recommended for the surgical treatment of trifacial neuralgia? What is the value of subcutaneous section of the nerve? About how long is relief obtained by this operation? Does excision give better results? How long may relief be obtained by this operation? What have been the results of nerve-stretching? What is the value of evulsion? How is evulsion practiced? Describe the operation for the subcutaneous division of the supraorbital nerve. Describe the operation for the excision of the supraorbital nerve. Describe the operation for the excision of the superior maxillary nerve. Under what circumstances is the removal of Meckel's ganglion sometimes undertaken? Describe the operation for the removal of this ganglion. In what particular locations may the inferior maxillary nerve be divided or excised? Describe excision of the inferior dental nerve at the mental foramen. Describe the steps in Garretson's operation for excision of the inferior dental nerve within the canal. What are the various steps in the operation for excision of the inferior maxillary nerve at the inferior dental foramen through the mouth? Describe the Pancoast operation and its objections. Describe the various steps of Cryer's operation for excision of the inferior maxillarv nerve at the inferior dental foramen through the cheek. CHAPTER XL. CONGENITAL FISSURES OF THE LIP AND THE VAULT OF THE MOUTH. Fissures of the upper lip, superior maxillary bones, and soft pal- ate are the result of arrested development of the parts involved, and consequent failure of these parts to form a junction and coalesce. The fissure may be of any degree from a slight notch in the lip or a bifurca- tion of the uvula, to a complete cleft of the lip, alveolar process, palate bones, and velum palati; or a double cleft of the lip and bony palate and almost entire absence of the velum. The slightest degree of fissure is represented by a superficial notch or scar in the upper lip, and by a mere suggestion of a bifurcation of the uvula. The most common forms are fissures of the lip and the velum. Fissures of the lip often occur without cleft of the velum or maxillary bones, while on the other hand cleft of the velum frequently occurs without fissure of the lip ; the cleft in the palate may even extend forward to the alveolar process, and still not be associated with a fissure of the lip; but where the fissure extends through the alveolar process the writer has always found it associated with a "fissure of the lip. "In some rare instances, however, the alveolar process alone may be fis- sured." Fissures of the lip and palate may be unilateral or bilateral; but are most frequently unilateral, and most commonly upon the left side. Figs. 143 and 144 are photographs of cases which have come under the care of the writer, and are inserted for the purpose of illus- trating some of the extremes in unilateral fissures of the lip and the vault of the mouth. In the child (male) represented by Fig. 143, there was complete cleft of the hard palate, velum palati, and right side of the lip, with marked protrusion and eversion of the intermaxillary bone; in all other respects the child was perfectly formed. No history of hereditary ten- dency or of maternal impressions could be deduced. Fig. 144, also a male child, has complete cleft of the hard palate, velum palati, and left side of the lip, with marked protrusion of the intermaxillary bone. The deformity of the face in this case is much greater than in the preceding one, while in other respects the child was 400 CONGENITAL FISSURES OF THE LIP, ETC. 401 defective in development, having an immense congenital scrotal hernia, — larger than a goose-egg, — and the fourth and fifth toes of the left foot united. Bilateral fissure of the lip and maxillary bones with protrusion of the intermaxillary bones and median cleft of the soft palate occasion- ally occurs. (Fig. 145.) The writer has operated upon several cases of this character associated with extensive protrusion of the intermax- illary bones. In each, of these cases there was no union of the palate process with the vomer on either side. In exceptional cases the fissures may extend upward on either side of the nose, or backward, involving the base of the skull. Median 1 fissure is very rare. Salter mentions three cases, one described by Fig. 143. J ■ ^^' ^ ^ HK^'fl^,, \ % ' .»'< '- ■J ■ ^% ^ ^^ s ii"H 1 K ^V .4^ *^ ^ COMPLETK ClkKI ok IHK MARKED Protrusion of VI Halau, and Right Side of the Lip, w Portion of the Jaw. Child 9 weeks ol Rokitansky, one met in his own practice, and a specimen in the Museum of the Royal College of Surgeons, London. Occasionally there is an entire absence of the maxillary bones, and consequently of the incisor teeth. A case of this character recently came under the observation of the writer in a female child six weeks old, in which there was a com- plete cleft of the hard and soft palates and fissure of the lip on the left side, with entire absence of the intermaxillary bone and the vomer. The cleft through the alveolar process measured five-eighths of an inch in width. The tip of the nose was greatly depressed, being but very slightly elevated above the level of the cheeks. The cartilaginous 402 SURGERY OF THE FACE, MOUTH, AND JAWS. nasal septum was also absent. The whole condition caused one of the most ugly deformities imaginable. There was no history of heredity or of maternal impression. In Salter's case of median fissure, the right intermaxillary bone was slightly deficient, with absence of the central incisor; the lateral, however, was in position standing close to the cuspid and separated from the left central by a deep fissure. Broca has reported quite recently a case of complete fissure of the upper lip with absence of the median tubercle. Fig. 144. Complete Cleft of Hard Palate, Velum Palati, and Left Side of the Lip, with marked Protrusion of the Intermaxillary Portion of the Jaw. Child 8 months old. Median fissure of the face is more often associated with the lower lip and inferior maxilla than with the upper portion of the face. A remarkable case of this character (Fig. 146) is reported by A. Wolfler, as occurring in an infant that came under his notice when it was twenty-three days old, in which the lower lip was cleft, the inferior maxilla separated upon the median line, but held together by a cica- tricial band; the fissure extending downward into the neck to the .'iupra- sternal fossa; the anterior portion of the tongue was likewise CONGENITAL FISSURES OF THE LIP, ETC. 4O3 divided into two halves upon the median hne. These deformities were successfully corrected by surgical operations. Sometimes there are other defects of development associated in the individual with fissure of the palate, due to the same general causes. These defects are occasionally of an extreme character and serious nature, and interfere with the performance of the natural func- tions of the body. Fig. 145. Double Hare- Lip. with protrusion of the inlennaxillary bone, and non-union of the maxillary bone with the vomer on both sides, making what might be termed a double cleft in the hard palate. The cleft in the soft palate was exceedingly wide, showing very imperfect development. Origin. — The origin and causes of hare-lip and cleft palate are to be sought for among the pre-natal influences, and are generally con- ceded to be faults in the developmental process. These influences to be operative must occur prior to the tenth week after conception. The formation of the maxilla begins at a very early period of intra-uterine life, viz: at about the twenty-eighth day by the development of four tiny buds, tubercles, or processes near the central portion of that sur- 404 SURGERY OF THE FACE, MOUTH, AND JAWS. face of the rudimentary head which is destined to form the face (Fig. 147), which are denominated the superior or frontal processes or tuber- cles, and the lateral or oblique maxillary processes or tubercles. The superior processes elongate downward, and at the same time approach each other toward the median line, where they finally coalesce to form the intermaxillary bones and the central portion of the upper lip. The latter processes likewise elongate and approach each other toward the median line, where they finally meet the superior processes and unite with them, thus forming the lateral halves of the superior maxillary bone, palate bones, the cheeks, and lateral portions of the upper lip and the velum palati. Fig. 146. Mkuian FissLKboi Hit LuwLK LiP isD CHI^ (After Wolfler.) Non-Union of Superior and Lateral Processes. — The frontal pro- cesses rarely fail to unite upon the median line; but it is not tmcommon for the oblique maxillary processes of either side to fail to unite with the frontal processes, and occasionally both sides fail; thus, in the former case producing a fissure upon the right or left side, and in the latter a double fissure. Fissures of the lip are the result of the same causes, viz: failure of the central portion of the lip to unite with the lateral portions, while CONGENITAL FISSURES OF THE LIP, ETC. 405 clefts in the velum palati are the result of a non-union of the lateral half with its fellow upon the median line. Arrested Development. — In many cases there is a deficiency in the various tissues which go to make up the complete superior max- illary bone, palate bones, lip, and soft palate; hence the primary cause would seem to be an arrestment of the developmental process in these particular parts. The writer has seen several cases in which the velum palati especially was very deficient and only rudimentary in character, while in others there was a marked deficiency in all of the tissues of these parts, leaving a broad, yaw-ning aperture. The extent of the fissure will depend very largely, if not entirely, upon the time at which the arrestation of development occurred; the earlier the period the more extensive the cleft, and vice versa. At about the fortieth day after conception the superior and lateral processes have united, and by the end of the tenth w-eek the vault of the mouth has been completed by the union of the velum palati and uvula Ftg 147 Superior Tubercle Lateral Tubercle Superior Tubercle Lateial Tubercle. Head of an early Hu.vian Embryo, showing the Disposition of the Facial Fissures and OF THE Superior and Lateral Tubercles. (After His.) through their entire length; this process begins at the anterior aspect, and progresses backward, the uvula being the last portion to unite. In certain cases of hare-lip and cleft palate there is a suf^ciency of tissues, the only fault seemingly being a failure of union of the parts at the proper time. These cases when treated surgically in the early months of infancy, generally secure normal position of the parts and a complete restoration of function. The fundamental influences, however, which underlie the causa- tion of these defects in development have not yet been reached, and all theories which have so far been advanced to account for them belong to the realm of speculation and conjecture. Faulty Nutrition. — Some have thought the trouble to be caused by a fault in the diet, through the exclusion of meat as an article of 406 SURGERY OF THE FACE, MOUTH, AND JAWS. food, or the introduction of an insufficient quantity of calcium phos- phates into the system of the mother difring gestation. As an argument in favor of this view it might be stated that the hons in the Zoological Gardens of London were fed for several years upon meat from large animals having bones too large for them to crush and swallow; this was followed by the birth of cubs with cleft palate,^ — 99 per cent., — which lived but a short time on account of their inability to suckle. The lions were then occasionally given a small animal, like a goat or sheep, the bones of which were readily crushed by their teeth, and the young afterward born had perfectly formed palates. At the Zoological Garden of Dublin a like experience was en- countered, and was counteracted by feeding the pregnant lions with ground bones and foods containing calcium phosphates. Dr. J. Ewing Mears reports the same condition prevailing among the offspring of the lions at the Philadelphia Zoological Garden. Neither of these arguments is entitled to very much weight, for the reason that it is a fairly well-established fact that union of the superior and lateral maxillary processes in the human subject is not dependent upon ossification of these structures, for union or coales- cence takes place in advance of ossification, and this process is not completed along the line of the sutures until some time after birth. It is also a well-established physiologic law that in the pregnant woman, if there is not a sufficient amount of calcium salts ingested to support the extra demands made upon the system for the proper devel- opment of the osseous framework of the fetus, and to recoup the waste in her own tissues, the material already stored up in her body is drawn upon to supply the demands of the fetus. Changes in the constituent elements of the bones are of common occurrence as a result of malnutrition. Dalton says, "Next to the chlorid of sodium, the phosphate of calcium is considered the most important ingredient of the body. It is met with universally in every tissue and every fluid," and "whenever the nutrition of the bone during life is interfered with from any pathologic cause, so that its phosphate of calcium becomes deficient in amount, a softening of the osseous tissue is the consequence, by which the bone yields to external pres- sure and becomes more or less distorted.'" In fractures occurring during gestation, union is often delayed, sometimes until after delivery. Padieu describes a case in which frac- tures of the tibia and fibula occurred nine days after the suppression of the menses, and in which union was delayed until the end of gestation. The process of union began ten days after delivery, and was completed at the end of a month. The pelvis, though looked upon at all other times as a compara- CONGENITAL FISSURES OF THE LIP, ETC. 407 lively solid framework, freqiientl)' becomes relaxed in its articulations during pregnancy, so that the sacro-iliac and pubic joints become movable. Many women are in the habit of discarding from their aliment during pregnancy all those foods which contain an abundance of cal- cium salts, and restrict themselves, as nearly as possible, to a fruit diet, believing that by such practice the bones of the child will be imper- fectly calcified, and thus parturition be robbed of much of its suffering. There is, however, no scientific evidence that such a result is obtained, while on the other hand, as in those cases affected with hyperemesis, though the child when born may be small and much emaciated, it has the appearance of being properly formed, and its bones as dense as in the majority of normal pregnancies. Heredity. — The question of hereditary influence is one that calls for more than a passing notice, for a priori it would strike one as likely to be an important factor in the production of defects of development. The facts, however, which have been deduced, are not of sufficient strength to establish it. A few isolated instances have been reported in which there seemed to be an indirect inherited tendency in a certain family to produce offspring with hare-lip and cleft palate. . Oakley Coles mentions two families in which there was a marked tendency in this direction. In the first family there were three with cleft palate, one seventeen years of age, another thirty, and the third thirty-five; the first and last were women. The man, who is married, has a family without a single instance of the father's deformity. The second family was composed of five children, two of whom had fis- sure of the lip and palate; the first child was born perfect, the second had single hare-lip and cleft palate, the third child was perfect, the fourth had double hare-lip and cleft palate, and the last child was perfect. The maternal grandmother also had cleft palate. Lawson Tait believes that heredity is a strong factor in the production of this deformity, and says he has known it to skip three generations and then appear in a hereditary form. E. F. Plicque reports a case of hare-lip in a female, in which he thinks the deformity is ttndoubtedly inherited. The family history is as follows: Both parents of the patient were entirely free from any congenital defect. One of her father's brothers had supernumerary fingers. A brother of her mother was born with hare-lip, but both of his children were free from the deformity. Her sister, the mother of the patient, has given birth to nine children, five of whom had hare- lip but no palatal defect. Another sister of the patient's mother, who was free from congenital defect, gave birth to two children with hare- lip and cleft palate of an uncommonly severe type. A brother and a 406 SURGERY OF THE FACE, MOUTH, AND JAWS. sister of the patient, both of whom had congenital hare-hp, had mar- ried, but neither of their five children had any sign of the defect. Manley says in all of his cases there was either a history of heredity or of maternal impression. The writer recently operated upon a child six months old, with double fissure of the upper lip and hard palate, with protrusion of the intermaxillary bones and only rudimentary velum, this being the sec- ond child born of the same parents, in whom the tendency was marked. The first child was born with fissure of the left side of the upper lip; the second child was born perfect, and the third child with the defect first described. There was no history of similar defects of develop- ment in the family of either of the parents. Maternal Impressions.— It is interesting to note in this connec- tion that most women who are so unfortunate as to give birth to deformed children, especially those with deformities of the face and mouth, feel very confident that it is the result of maternal impressions induced by fright, the sight or knowledge of a like deformity, etc. How much, if any, there may be of scientific truth in this popular no- -tion the writer is not prepared to say, more than that in all popular notions there is generally somewhere hidden away a kernel of truth. When we know more about the infiuence which the nervous system exerts over cell-life, the effects of the physical and mental conditions of the parents at the time of conception, and of the female parent during gestation, we shall be better able to consider the question from a scientific standpoint; till then it would be mere speculation. Prognosis. — Most of the fissures and perforations of the hard palate are susceptible of radical cure by plastic surgical operations; the excep- tions being those cases where there is marked deficiency in develop- ment, or loss of tissue, and even in these there is reason to hope that the operation of transplanting new tissue from some adjacent locality will be so perfected as to become not only feasible as an operation, but successful in re-establishing the functions of the parts. In clefts of the velum palati where the fissure is very wide and the deficiency in tissue is considerable, it is better to depend upon the artificial velum, rather than to attempt a cure by surgical measures; for unless the velum can be restored to its normal length so as to perfectly close the naso-pharyngeal opening, the operation would be a failure, from the practical standpoint, for restoration of function is the main object in view. The enthusiasm of the surgeon has many times carried him be- yond the limits of a wise conservatism in the treatment of these cases, especially in operations upon the velum, with the natural result, failure. Consequently there are those who decry all attempts at cure by a surgi- cal procedure, and maintain that in all cases mechanical appliances CONGENITAL FISSURES OF THE LIP, ETC. 409 accomplish the best results in restoring the functions of the parts. A wise conservatism in both directions will, in the writer's opinion, give the best results in the individual case, for in no department of surgery is good judgment of more value to the patient. The mortality of operations for iissure of the lip and palate, according to the investigations of Hofifa, is greatly influenced by the deformity itself. From the records of 114 cases of hare-lip, twenty- seven deaths occurred, giving a mortality of 23.7 per cent.; while out of III cases of complete fissure of the lip and palate operated upon, there were forty-three deaths, making the mortality 38.73 per cent. Boiling maintains that although the mortality rate is high in oper- ations for the correction of these deformities, it does not very much exceed that of children of the same age. Although the writer has not statistics at hand to substantiate his opinion upon this question, he yet feels sure that this rate of mortality is considerably higher than for such operations among American surgeons. REVIEW. CHAPTER XL. What do hare-lip and cleft palate result from? What are the slightest degrees of fissure of the lip and palate? What are the more severe degrees of fissure? Does cleft of the lip occur without fissure of the vault of the mouth? May fissure of the vault occur without cleft of the lip? If the fissure extends through the alveolar process, is there cleft of the lip? Which form of fissure is most common, unilateral or bilateral? Which side is most commonly fissured? Are the intermaxillary bones sometimes undeveloped? Do the lateral fissures ever extend beyond the lip and vault of the mouth? Do median fissures ever occur? With what part of the face are they most frequently associated? What are the causes of fissures of the lip and vault of the mouth? At what period of intra-uterine life do the jaws begin to develop? What are the first evidences of this development? How do these tubercles unite to form the upper jaw, soft palate, and lip? How are simple fissures produced? How are double fissures produced? What is the cause of failure of union? At what period of intra-uterine life is the process of union completed in the vault of the mouth? At what part of the vault does this process begin, and which is the last part to unite? May faults in nutrition be a factor in causing non-union of the parts? 4IO SURGERY OF THE FACE, MOUTH, AND JAWS. May faults in diet be a cause? What physiologic law is opposed to this? Is heredity an important factor in the causation? May maternal impressions have an influence in causing the deformity? In what class of cases is the prognosis favorable for cure by surgical •operation? What are the main objects to be attained in radical cure by a surgical operation? What condition must be obtained in the velum palati to restore the func- tions of deglutition and speech? Are all cases of cleft palate susceptible of cure by a radical operation? What should govern the surgeon in these questions? What class of cases are not amenable to surgical cure? What is the best treatment in these cases? What is the stated mortality of operations for fissure of the lip? What for operations of fissure of the palate? CHAPTER XLI. CONGENITAL FISSURES OF THE LIP AND THE VAULT OF THE MOUTH (Continued). Surgical Treatment. The operations which are practiced for closing the fissures of the palate are designated as uranorrhaphy and staphylorrhaphy. Uranoplasty or uranorrhaphy is the operation for closing a fissure in the hard or bony palate, while staphyloplasty or staphylorrhaphy is the term ap- plied to the operation for closing a cleft in the soft palate or velum palati. Chiloplasty or chilorrhaphy is the operation for closing a fis- sure in the lip. Lemonnier, a French dentist, is credited with having been the first to suggest and to successfully operate for the closure of fissures of the palate by surgical operation, the record having been published in 1766. Lemonnier succeeded in closing a fissure in both the hard and soft palates, by paring the edges of the cleft with a knife, and approximating them by the use of sutures. Perforations in the hard palate he success- fully closed by exciting granulation of their borders. Eustache, a physician of Beziers, in 1799 recommended the same procedure to a patient for whom the day before he had split the soft palate for the purpose of removing a polypus of the pharynx. The operation, however, was declined by the patient. In 1800 he pre- sented a paper upon the subject of closing congenital fissures of the soft palate to the Academic Royale de Chirurgie at Paris, asking their approval of the operation, but this they declined to grant. Von Graefe revived the operation in 1816, and reported to the Medico-Chirurgical Society of Berlin that after many unsuccessful efforts to close fissures of the soft palate he had at last obtained success by freshening the edges by the application of muriatic acid and the tincture of cantharides, and then approximating them with sutures. The operation was modified by Roux, in 1819, who closed a fissure of the palate by paring the edges and applying sutures. Warren, of Boston, in 1820, being ignorant of the efforts of the other surgeons, performed successfully a similar operation. After this time the operation became generally known and practiced. 411 412 SURGERY OF THE FACE, MOUTH, AND JAWS. To Sir William Fergusson, of England, however, belongs the credit, more than to any other surgeon, of first demonstrating and giv- ing to the world a scientific basis for the requirements of the operation of staphylorrhaphy. The first important question in relation to the surgical treatment of cleft palate is that of the age of the child which gives the best pros- pect of a successful issue of the operation, and the restoration of the parts to normal function. Experience has taught the writer that skillful operations for clos- ure of fissures of the palate when performed during the early months of infancy are more successful in restoring the functions of deglutition and articulation than when postponed, as is generally advised, until after the eruption of the deciduous teeth, or even to as late a period as the fifteenth year. In order to obtain the best results, the operation should be completed before the child begins the first attempt at articu- late speech. When delayed until after speech has been acquired, it is much more difficult to overcome the peculiar nasal tone that always ac- companies the voice in persons with perforations, or clefts, of the bony palate or velum. Another argument for early operation is the facility and comparative safety with which infants can be brought under the control of anesthetics, and the ease with which anesthesia can be main- tained, and this is a great desideratum in all operations upon the mouth. Chloroform has the preference, with the writer, for operations upon little children. In complete clefts of the upper lip and maxilla there is a noticeable broadening of the face upon the affected side; the distance from the median line of the apex of the nose to the antero-inferior angle of the malar bone is greater than upon the perfect side, and there is also accompanying this a decided spreading out and flattening of the ala of the nose. (Fig. 148.) When the lip has not been closed this broadening of the face and flattening of the ala of the nose increase with the growth of the individual. On the other hand, in those cases where the lip has been closed early, this widening is not only prevented, but there seems to be a slight narrowing of the cleft, due no doubt to the muscular contraction of the united lip. An early operation should therefore be recommended for the closure of the lip and, where the strength of the child will permit, of the fissure in the bony palate and velum as well, provided the condition of the velum gives promise of successful restoration of function. A second operation for the closure of the velum can be done a few months later if the condition of the child is not favorable for such procedure at the time of closing the fissure in the hard palate. Operations. — In operations about the mouth the choice of anes- thetics must be governed by the age of the patient and the general con- ditions of health. Chloroform is the pleasantest for all mouth-surgery, CONGENITAL FISSURES OF THE LIP, ETC. 413 especially in operations upon the velum, on account of the fact that it is not so liable to cause vomitino- or irritation of the bronchial :-Lip AND Cleft Palate. Fig. 149. Chloroform Inhaler and Drop-Bo mucous membrane as is ether, though it has the disadvantage of being much more dangerous to life. Little children, however, as a rule, bear chloroform much better than adults, and it may therefore be adminis- 414 SURGERY OF THE FACE, MOUTH, AND JAWS. tered with comparative safety, and also much better after-effects. A most convenient method of administering chloroform is by use of the inhaler and drop-bottle (Fig. 149), though it may be administered upon a handkerchief or a napkin. When administering ether, the inhaler. Figs. 150 and 151, will be found most convenient and useful. The position of the patient in operations upon the vault of the mouth is one that needs careful consideration, on account of hemor- FiG. 150. Fig. 151. rhage, which is often quite profuse when operating upon the hard palate by the Langenbeck method, and the difficulties sometimes ex- perienced in getting good illumination of the parts. The position shown in Fig. 152 is the best under nearly all circumstances, as it per- mits the blood to escape by the nostrils instead of into the throat, and at the same time gives a good view of the parts if the operator stands at the head of the patient. CONGENITAL FISSURES OF THE LIP, ETC. 415 The instruments needed in performing a staphylorrhaphy are: a mouth-gag, a Mason's or a Whitehead's (Fig. 153), a sharp-pointed curved bistoury (Fig. 154), a pair of mouse-tooth tissue-forceps (Fig. 15s), a pair of curved needles — right and left — with handles (Fig. 156), a suture pick-up (Fig. 157) and a wire-twister (Fig. 158), a pair of small, long-handled scissors, silk and silver wire sutures, perforated shot, and a shot compressor. Fig. 152. Position of Head durinl, OptR^TioNS on the Mouth (Alter Murphy.) Fig. 153. Whitehead Gag. In operating upon a simple hare-lip, a bistoury or the hare-lip scissors may be used for paring the edges of the cleft. (Fig. 159.) In a flap operation upon the lip the bistoury or a small scalpel is the best for this purpose. A pair of lip-compressors (Fig. 160) will also be found serviceable for controlling the hemorrhage. The lip may be united either with the hare-lip pins and the figure of 8 suture, or with the interrupted suture of silk or catgut. 4l6 SURGERY OF THE FACE, MOUTH, AND JAWS. F(G. 154. ijiiiiiiiiiiiiiiiiiiuinaiiii Curve-pointed Staphylorrhaphy Bistoury. Fig. 155. Special Staphylorrhaphy Screw Forceps. Fig. 156. a^ Hare-Lip Scissors. Fig. 160. Lip Compressor. CONGENITAL FISSURES OF THE LIP, ETC. 4I7 Hare-Lip. — In uniting fissures of the lip it is important to con- serve as much of the tissue as possible, in order that the lip may not be unnecessarily contracted. Various methods have been devised to give a normal shape to the free border of the lip and to prevent the notched condition which so often follows hare-lip operations. In all operations for closing fissures of the lip it is important to dissect the lip from the alveolar process upon either side of the cleft for a considerable distance backward, in order to gain as much tissue as possible and to prevent strain upon the freshly-united edges of the cleft. The common method of uniting a cleft in the lip is simply to pare the edges with a curved bistoury, inserting it at the angle of the cleft upon one side and then ypon the other, and carrying it through the lip to the vermilion border, removing a paring the full thickness of the lip, or obtaining the same result by trimming the edges with the hare-lip scissors. The edges are then brought together with sutures of silk, catgut, or hare-lip pins. The lip-compressor may be necessary to con- trol the hemorrhage from the coronary arteries until the sutures are ready to be placed. Tying of these vessels is rarely if ever necessary. Fenger, of Chicago, has lately devised a new operation for hare- lip, which consists essentially of utilizing the parings of the fissure to lengthen the border of the lip, splitting the edges of the flaps and unit- ing the edges of the mucous membrane and the skin by separate lines of sutures, this part being similar to the operation of Tait for uniting the lacerated perineum, and also that of Marcy for closing the velum palati. Fillebrown, of Boston, recommends the following operation, which is similar to that devised by Nelaton, for relieving the notched condition of the lip so frequently seen in the border after operation for single fissure of the lip : "A male, aged thirty, a patient in the Harvard Dental Hospital, came to have an obturator constructed for cleft palate. The cleft in- volved the hard as well as the soft palate, and originally a hare-lip. The lip had been operated on, and of course much improved, but the characteristic notch was present. (Fig. i6i.) "It had long been my belief that this deformity could be remedied, and I hailed with pleasure the opportunity to apply the remedy. "The operation performed for it is shown in the illustration here presented. It was the result of study, experiment, advice, and acci- dent, and its success entirely fulfilled my expectations and hopes. "By comparing the two cuts and noting the position of the letters, the operation will be fully understood. "The line a-b. Fig. 162, represents the cicatrix left by the former 28 4i8 SURGERY OF THE FACE, MOUTH, AND JAWS. operation. The line c-d shows the Hne of the incision transversely across the hp. "Fig. 163 shows the incision made vertical by drawing the lip down and inserting a suture and drawing the points g-h, representing c-d of Fig. 162, close together. This converted the horizontal in- cision into a vertical one, and lengthened the lip at that point by just the length of the cut. "Fig. 161 shows the case as photographed just previous to the operation. The notch was so considerable as to show the patient's lateral incisor tooth continually. "Fig. 164 shows the case as photographed after the lip had healed. "The approximation of the lips was perfect, and but ver}- little narrowing of the red border was perceptible. Fig. it Fig. 164. FiLLEBROWN'S OPERATION. "The excessive size of the nostril was reduced by a A-^-shaped in- cision, taking out a piece of the wall of the nostril and drawing the edges together. This was entirely independent of the lengthening of the lip. "The operation proved an entire success." In cases of single cleft of the lip and palate the writer advises the closing of the lip as soon after birth as the condition of the child will permit, and the operation upon the bony palate and velum from the sixth to the twelfth month. In operating for single hare-lip, preference is given to the Mirault method as most likely to produce a lip of normal length and width. This consists of bringing down a flap from one side, sliding it across the cleft, and attaching it to the pared opposite side. Fig. 165 is the result of a Mirault operation upon the child, Fig. 143, photographed ten days after the operation. The intermaxillary bone was brought into position by fracturing the bone upon the left side and uniting the edges of the cleft in the maxilla by a wire suture. Owen's operation, Figs. 166 and 167, is quite similar, although the incision for making the CONIIENITAI. FISSURES OF THE I.IP, ETC. 419 flap is carric'il iiitcj the lip somewhat deeper. 'I'his incision gives the fulhiess to the Hp where most needed. In closing the hard palate in these cases the writer prefers the Langenbeck operation — muco-perios- teal flap — from the fact that in a majority of instances it succeeds in filling the gap with osseous tissue. In cases of tlouhlc cleft of the lip and palate with protrusion of the intermaxillary tuhercle. ojn'ration slumld he advised at the earliest Fig. 165. 1 1 ^r *' "^ 1 V ■> -^ 'T^ ^^^s ^ .. ^ Operation ] Closur ;iissioN OF THE Intermaxillary Portion of ruE Jaw ■: Hare-Lip. Ten Days ai-'Ter Operation. possible day, as these children are prevented from taking the breast or even the bottle; feeding by the spoon is therefore the only method that can be used, and on account of the difficulty in swallowing, they as a rule do not obtain sufficient nourishment to properly sustain the functions of life, and as a result many dwindle away and die. Earlv correction of the deformity in the anterior portion of the mouth is. therefore im]ierative. 42a SURGERY OF THE FACE, MOUTH, AND JAWS. It is customary with most surgeons in operating upon these cases to cut away the protruding intermaxillary tubercle and close the lip upon the median line. This certainly is the easier method, but it is open to serious ob- jections; first, because this portion of the maxilla contains the incisor Fig. i66. Fig. 167. Owen's Ope Owen's Operat teeth; second, because it removes the bony column upon which the nose rests; and third, because it produces an extreme narrowing of the face in the incisor and cuspid regions, with more or less complete stenosis of the nostrils, a deformity which can never afterward be remedied. The preferable method is to replace the intermaxillary tubercle by removing an inverted V-shaped section from the vomer, carrying the tubercle into position and retaining it there by a wire passed through holes drilled in the vomer anteriorly and posteriorly,- to the point of section, and allowed to remain until union has taken place. Fig. I If the lateral surfaces of the tubercle now come in contact with the lateral halves of the maxilla, the occluding surfaces should be freshened, and one or more fine silk sutures passed through the gum- tissue upon either side. When the surfaces do not occlude and the separation to be overcome is not very great, forcible pressure can be made upon the malar bones by the hands of the operator until the CONGENITAL FISSURES OF THE LIP, ETC. 421 surfaces meet, and afterward held in position by means of the Hanesby truss (Fig. i68) or rubber bandage, as suggested by Garretson. In closing the lip, it is preferable to utilize the central portion if it is of sufficient width to admit the passage of sutures, rather than to cut it away, and unite the lip upon the median line. The Golding-Bird operation is the one usually practiced by the writer in these cases; it consists in removing the vermilion border on all sides, leaving the prolabium with straight edges. The lateral halves of the lip are then dissected from their attachment to the bone, and pared to fit the trimmed prolabium. In order to obtain a suffi- cient amount of tissue to form a good lip, it sometimes becomes neces- sary to carry an incision around the ala of the nose and into the cheek. A deep suture is passed near the border of the lip, just above the edge of the mucous membrane, and another at the lower border of the ala of the nose to give proper shape to the nostrils, — it is often impossible to pass more than these, — and the edges of the skin and mucous mem- brane brought into nice apposition with fine interrupted silk sutures. To relieve tension and protect the wound it is covered with a collodion dressing, and over this an adhesive strip. The writer prefers to replace the maxillary tubercle and close the lip at the same time. Operation upon the fissured palate should be deferred till a later period. This operation he has performed several times with uniformly good results. One child was but six days old, but the operation was borne well, and he took the breast three hours afterward. The others were between two and six months old. Uranorrhaphy. — In operations upon the bony palate — urano- plasty — the writer usually prefers the Langenbeck method, which con- sists of first paring the edges of the cleft; second, making an incision through the soft tissues covering the hard palate close to the teeth, and lifting these tissues from the bone with a curved periosteotome, sliding them over the fissure, and uniting the periosteal surfaces together with the cobbler's stitch or suture. This method of stitching is a modifica- tion suggested by the writer, and gives more satisfactory results than the old method of uniting the edges by the interrupted suture. Fergusson's operation consisted of drilling the bony palate at short intervals from before backward, and then splitting it with a chisel. The edges of the cleft having been previously pared, are then united by silver wire sutures. •Billroth has recently modified the Langenbeck operation for clos- ing fissure of the hard palate and velum, by approximating the internal wings of the sphenoid. This he accomplishes by dividing the mucous membrane at the sides of the velum, and fracturing the bone with a chisel. The mucous membrane is then utilized to close the cleft. His object is to do awav with the necessity of dividing the muscles of the 42i SURGERY OF THE FACE, -MOUTH, AND JAWS. velum, particularly the circular or sphincter muscle which surrounds the naso-pharyngeal opening, and which has its anterior fibers in the velum palati. Rotter, of Munich, describes an interesting case of a child six years old, upon whom he had operated previously by the Langenbeck method for an uncommonl}' wide fissure : the muco-periosteal flaps had united upon the median line by first intention through their entire length, but left an opening upon the left side near the teeth, about four- tenths of an inch in width, giving free communication between the mouth and nasal cavit)'. To close this opening he raised a flap of skin from the forehead (Fig. 169), having a long pedicle attached, and the Fig. i6y. Rotter's Operation for Cleft Palate. (After Rotter. ) gap in the forehead was immediately closed with sutures (Fig. 170). He then placed upon the raw surface of the flap numerous epidermal grafts after the method of Thiersch, placed the flap against the fore- head with the raw surface undermost, and held it in position by a bandage. At the end of eight days the grafts had taken, and the flap was covered with skin upon both sides. The next steps were to lengthen the incision along the right side of the nose to the cleft in the lip. raise the right ala of the nose, freshen the edges of the opening in the palate, stitch the flap into position, close the fissure in the lip, and re- place the ala of the nose. (Fig. 171.) CONGENITAL FISSURES OF THE LIP, ETC. 423 The case was successful, and Rotter exhibited the child two years later to the Congress of German Surgeons. One of tlie remarkable facts in the case was that though the flap was covered upon both sides with skin, the moisture in which it was constantly bathed seemed to have no deleterious effect upon it. Rotter states that only two other cases are on record in which tissues had been transplanted for a like purpose from other locations than the palate itself, the first by Blaisus, the second by Thiersch. Brophy, of Chicago, has recently devised a new method of approx- imating the edges of fissure of the palate which is unique and original, and for which he claims a decided advantage over other operations. Fig. 170. Fig. 171. Rotter's Operation for Cleft Palate (After Rotter.) ;'s Operation for Cleft Palate. (After Rotter.) The method consists substantially in passing two double silver wire sutures through the superior maxillary bone, within the mouth; the posterior one inserted just behind the malar process, and high enough to pass over the palate plate of the bone, emerging at the same point upon the opposite side; the anterior one is passed through the bone just in front of the malar process. A lead button having two eye- holes is threaded upon the wire, and the ends twisted together. The edges of the cleft having been previously freshened, the wires are twisted until the edges of the cleft are brought together. If the re- sistance is such that the edges do not readily approximate, the malar 424 SURGERY OF THE FACE, MOUTH, AND JAWS. process is divided on either side by the aid of a heavy scalpel. The edges of the cleft are united by sutures in the usual way. This operation would seem to be valuable if performed during the early months of infancy, while the bones are still imperfectly calcified, in those cases where the deficiency of tissue is slight and the edges of the fissure but moderately separated. Where the cleft is wide and the deficiency of bony tissue considerable, it might succeed in closing the defect in the palate; though it would establish another deformity equally grave in character, viz: partial or complete stenosis of the nasal passage of the affected side. It is to be presumed, therefore, that Brophy would not advise this operation, only in selected cases where this condition could not result. In the cases first mentioned it would seem to have an advantage over the Langenbeck muco-periosteal operation ; but in fissures of any considerable width, or in double fissure, the latter procedure would be preferable. Staphylorrhaphy. — A modification of Nekton's operation for bifid uvula and single hare-lip has, in the hands of the writer, given good results when apphed to closing the velum palati. This method is especially adapted to those cases where the cleft in the velum is the only oral defect. The usual method is to freshen the edges of the velum with a bold hand — most surgeons claiming that successful union is more often obtained by this method than when less tissue is cut away. This, so far as obtaining good union is concerned, is a self-evident fact; but why sacrifice tissue when there is generally so little in the first place to operate upon? The main object is to restore function, and this can only be accomplished by restoring the velum and uvula to their proper width and length, so as to insure a perfect occlusion of the naso- pharyngeal opening. In paring the cleft by either the bold or conservative method, the parings are usually sacrificed. B3' the method which is now presented the parings are utilized to broaden and lengthen the velum and form a new uvula. In the act of deglutition the velum palati is drawn up against the walls of the pharynx, the base of the uvula filling the depression upon the median line formed by the approximation of the two sides of the pharynx, thus perfectly closing the naso-pharyngeal opening and pre- venting the escape of food into the nasal passages during the act of swallowing, and materially assisting in the production of articulate speech by preventing the escape of certain sounds through the nasal passages. By the modified Nelaton operation every particle of tissue is saved CONGENITAL FISSURES OF THE LIP, ETC. 425 and carried to that part of tlie velum where it is most needed to im- prove the shape, the width, and the length. The method is similar to that often practiced upon single hare- lip, viz: a curved, pointed bistoury is inserted just above the apex of the cleft, and carried downward toward the uvula of one side, about one line from the cleft at the apex, gradually increasing the distance as ttlpi,,, Cleft of the Soft Palate, Fig. 173, the bistoury approaches the uvula to about two lines from the edge of the cleft and three lines from the posterior border of the velum. This incision is repeated upon the opposite side. The apex of the paring is then carried backward, and the fresh- ened edges of the palate, after having been split to the depth of about one-fourth of an inch, are approximated and sutured. The object in 426 SURGERY OF THE FACE, MOUTH, AND JAWS. splitting" the palate is to gain a broader surface of tissue at the edges of the cleft, and thus increase the chances of primary union. Three or four sutures are usually inserted, silver wire being given the preference as less likely to induce suppuration or ulceration about the sutures. Tension is relieved when necessary by dividing the tensor palati muscle upon either side, but this procedure is by no means always indicated. The after-treatment consists in keeping the wound and sutures as clean as possible by swabbing and spraying the parts with the Thiersch antiseptic solution at least every two or three hours. The sutures are allowed to remain from four to ten davs, according to indications. Fig. 174. Cleft Palate Treated by Kingsley's Artificial Velum. Mechanical Treatment. — The mechanical treatment of cleft pal- ate by means of artificial vela has through the inventive genius of Dr. Norman W. Kingsley been brought to a very high degree of perfec- tion. In no department of mechanical surgery has a greater achieve- ment been recorded than in the invention of the artificial flexible velum. All efforts in the direction of mechanisms for closing congenital defects in the palate which preceded the apparatus of Kingsley were crude, clumsy, rigid affairs, and of but little practical utility to the patient. The discover}' by Goodyear of the process of vulcanizing rubber made it possible for Kingsley to construct an appliance from a material which by its adaptability could be readily formed in moulds made from accurate impressions of the defective parts, and adjusted to them in such a manner as to be free from irritation. The form of the appli- CONGENITAL FISSURES OF THE LIP, ETC. 42/ ance is such that it is under complete control of the muscles of the parts, rising, and falling with the contraction and relaxation of the levator palati muscles, thus opening and closing the naso-pharyngeal space and preventing the regurgitation of fluids into the nose and making it possible with proper training of the vocal organs to attain comparatively perfect speech. Fig. 172 represents a typical case of congenital cleft of the velum palati. Fig. 173 shows the mechanical construction of the velum and plate to retain it in its position in the mouth. In Fig. 174 the velum is shown in its position. REVIEW. CHAPTER XLI. Who first performed the operation of staphylorrhaphy, and at what date? Who revived the operation, and at what date? What was the date of Roux's first operation? When did Warren make his first operation? To whom belongs the credit of first demonstrating and giving to the world a scientific basis for the operation of staphylorrhaphy? What is the first important question in relation to the surgical treatment of cleft palate? At what age is the best time to operate for cleft palate? Why are operations more successful at this age? What abnormal conditions are prevented by an early operation? What anesthetic is best in mouth operations? What is the best position of the patient for the operation of staphylorrha- phy? Why is this position valuable in this operation? What important fact should be borne in mind in uniting fissures of the lip? How may tissue be joined and strain be prevented upon the freshly united edges? Describe the common method of closing fissures of the lip. Describe Fenger's operation for hare-lip. What age is the best time to operate for hare-lip? Describe JMirauIt's operation for hare-lip. What is the surgical procedure in double hare-lip with protrusion of the intermaxillary bone? Why is an early operation advisable? What is the usual procedure in reference to the intermaxillary bone? What is the object in conserving this portion of the maxilla? What is the preferable method? How may this be done? What means can be used to unite the intermaxillary with the lateral halves of the maxilla? What should be done with the central portion of the lip in these cases? Describe the Golding-Bird operation for double hare-lip. 428 SURGERY OF THE FACE, MOUTH, AND JAWS. Describe the Langenbeck operation for closing the hard palate. Describe Fergusson's operation. What is Billroth's modification of the Langenbeck operation? Who made the first operation for transplanting tissue to close a cleft in the palate? How many operations of this character are on record, and who were the operators? Describe the Brophy operation. Has this operation any advantage over the Langenbeck operation? What are the dangers from the Brophy operation? What is the value of the- Langenbeck operation over the others? Describe the Nelaton operation, as modified by the writer, for closing the soft palate. What are the advantages of this operation? What is the after-treatment of operations upon the palate? CHAPTER XLII. TUMORS. Before entering upon a description of the tumors of the face, mouth, and jaws, it will be of advantage to consider briefly the origin, structure, growth, character, and classification of tumors in general. Definition. — Tumor (Latin Tnmere, to swell). A tumor is an enlargement or swelling of a part. A better defin- ition, and one more in accord with the later and stricter use of the term, is "any new growth not the result of inflammation or hyper- plasia." In the later classification of tumors by pathologists, a sharp dis- tinction is drawn between tumors, inflammatory swellings, and reten- tion cysts. Inflammatory hyperplasia of tissue due to infection by micro-or- ganisms is sometimes mistaken for a neoplasm, and vice versa. The difference between them, however, may be recognized by several im- portant features in their history. In inflammatory swellings, the growth and extension are often very rapid and progressive, but not continuous nor permanent. There is lack of definite outline ; they are amenable to agents which promote absorption by neutralizing or re- moving the primary cause, and they are subject to early and acute degenerative changes. An acute suppurative inflammation, on ac- count of its violent local and general symptoms, is rarely mistaken for a malignant neoplasm; while, on the other hand, new growths are usually characterized by their definite outline, slow but progressive growth, permanency of the new-formed tissue, and their resistance to internal medication. In certain forms of innocent tumors, like neuroma and osteoma, growth becomes spontaneously arrested when they have reached a definite size. The nearer the new growth resembles normal tissue, the greater the probability that it will be spontaneously arrested in its growth. Occasionally, in rapid-growing malignant neoplasms, such inflammatory symptoms as enlargement of the superficial veins and edema may be present. Senn emphasizes the fact that the nearer a malignant tumor resembles an inflammatory swelling the greater is its malignancy. 429 430 SURGERY OF THE FACE, MOUTH, AND JAWS. Origin. — Nearly all new growths originate from misplaced em- bryonic cells, and this constitutes the matrix from which the tumor is developed. Cohnheim was of the opinion that all tumors were of con- genital origin, and were developed from a matrix of embryonic tissue. Manner of Production of Traumatic Epithelial Cyst. (After Garr^.) £2, skin ; d, subcutaneous tissue ; c, dislocated fragment of skin. while Garre, Senn, and others believe they may be occasionally of post- natal origin, and independent of causes arising from the action of micro-organisms, — that they may be derived from pre-existing mature cells, which in consequence of injury or disease fall short of complete Beginning of Healing of the Skin-Defect and Commencing Proliferation from the Margins of the Implanted Skin. (After Garr6.) differentiation, thus forming a tumor-matrix, from which a neoplasm may be developed in the same manner as from embryonic cells which have been misplaced during fetal life. Figs. 175, 176, and 177 illus- trate the origin of a post-natal epithelial tumor. Fig. 177. Wound entirely Healed, and the Buried Skin-Graft enlarged by Proliferation from THE Surface and Margins of the Graft. (After Garr^.) Cohnheim was the first to teach that all tumors were developed from embryonic tissue, and to trace their origin to the various layers of the germinal disk. Ziegler, however, looks upon the theory of Cohnheim as more or less hypothetical, and the present knowledge of TUMORS. 431 the etiology of tumors in general as still very defective. He considers the histologic evidence of the existence of embryonal germinal tissue in the fully developed organism as very inadequate, and that it is a "bold step to ascribe an embryonic origin to all forms of tumors." The two latest and most reliable authorities upon the subject of tumors — Sutton, "Tumors, Innocent and Benign," 1893, and Senn, "Pathology and Surgical Treatment of Tumors," 1895 — both accept the teaching of Cohnheim in relation to the congenital origin of nearly all forms of neoplasms and their development from misplaced embryonic tissue. Germinal Layers.^ — Pander discovered, in 1847, that in the em- bryo of the chick the germinal disk was composed of three layers, — the external he denominated the serosa: the internal, the mucosa; and the middle, a muscular layer. They are now usually designated as the external layer or epiblast, the internal or hypoblast, and the middle layer or inesoblast. The layers can be plainly distinguished and their complicated arrangement readily traced in the embryo of the chick on the second day of incubation. (Fig. 178.) cA aw ao sp 'tJ tif Transverse Section through Embryo of Chick Two Da\s Old. : loo. (After Kolliker.) rfrf, hypoblast ; t'A, cord ; u7v, primitive vertebra; link, primitive vertebral canal; ao, primitive aorta; ung, primitive urinary canal ; sp, cleft in lateral plates (first indication of pleiiro-peritoneal cavity), which though lost in the/^yi and intestinal connective-tissue plates df, are connected through the mesoblast nip: vtr, meduUarj' tube; //, epiblast thickened at some points. The embryo at the time is composed of two epithelial layers, the outer the fpihlast^ the inner \.\\e. hypoblast, connected by the middle layer, the mesoblast. Embryologists trace the origin of all the tissues and organs of the vertebrate animals, including the human species, to these three general layers, which may be distinguished in the various embryos during the first few days after conception. From the epiblast are developed all those tissues and organs of epithelial structure, the skin and its glandu- lar appendages, the hair, the nails, the lens of the eye, the brain and spinal cord, the epithelial lining of the mouth, the nasal passages, the labyrinth of the ear, and the teeth. From the hypoblast there are devel- oped the mucous membrane of the entire alimentaiw tract, with all its glandular appendages, the urinary organs, the liver, the lungs, the thy- roids, and the kidneys. From the mesoblast is formed the great bulk of the body, viz: The bones, the connective tissues, the muscles, the nerves, the serous membrane and its glands, the vascular organs, the lymphatics, the ductless glands, the thymus, and the spleen. 432 SURGERY OF THE FACE, MOUTH, AND JAWS. In the differentiation of the cells which takes place in the embryo, each cell is endowed with its own particular genetic function of form- ing other cells like itself, but farther than this it cannot go. Cells may be arrested in their growth, and their character thereby somewhat changed, but there is never a transition from one variety to another, and this law remains in force during the entire life of the organism. When incomplete differentiation has taken place in some mis- placed portion of one of these germinal layers, it often remains buried in the tissues in its embryonic state for an indefinite period, but it may take on active growth at any time, with the result of invariably produc- ing a tumor corresponding in its structure to the variety and stage of development of the cells from which it had its origin. Structure. — "A tumor-matrix of congenital origin always repre- sents normal tissue-elements in an abnormal place." (Senn.) The histologic structure of the tissue which composes a new growth is governed by the inherenti genetic function of the embryonic cells which form the tumor-matrix. A matrix derived from the epiblast or the hypoblast would invariably produce a tumor of the epithelial type, while if derived from the mesoblast the result would be the formation of a tumor of the connective-tissue type. Senn maintains that the character of the neoplasm "depends upon the stage of arrested cell- growth" in the tumor-matrix. The nearer the tissue composing the tumor-matrix approaches the completion of the process of cell-differ- entiation, the greater the probability that the tumor which may be developed from it will be benign in character, while, upon the other hand, the nearer it resembles embryonic tissue — the more immature the cells — the greater the liability that the tumor will be of a malignant type. A tumor-matrix derived from the epiblast or the hypoblast, and composed of cells in which the process of differentiation has been almost completed, would give rise to a benign tumor of the epithelial type, viz: a papilloma, or an adenoma, while if composed of cells in which this process was arrested in its earlier stages, it would result in the formation of a malignant tumor of the same type, an epithelioma or a carcinoma. Senn makes no distinction in malignant tumors of the epithelial type, but classes them all as carcinomata. In tumors arising from the mesoblastic layer, the same conditions are manifest; a tumor-matrix composed of connective-tissue cells of high differentiation will produce an innocent tumor of the connective- tissue type, viz : A fibroma, chondroma, or an osteoma, while if of low differentiation it will be likely to result in the development of a sarcoma. The structure of benign tumors so closely resembles normal tis- sue, both macroscopically and microscopically, that it is many times TUMORS. 433 exceedingly difficult to distinguish between them. The same is true of their cellular elements. The cells retain the original form and type of the tissues from which they had their origin, and as they reach their highest degree of development it becomes almost impossible to dififer- cntiate between the tumor-cells and the normal cells representing the tissue from which the}' originated. The structure of malignant tumors is distinguished by the embry- onic or immature character of the tumor-cells, which closely resemble the fixed-tissue cells in their early stage of development. "The strik- ing difference between a sarcoma cell and an immature connective- tissue cell is in the size and number of their nuclei." (Senn.) In the sarcoma cells the nucleus is large and often multiple, while in the connective-tissue cells it is single and much smaller in comparison with the nucleus of the sarcoma cells. Another distinguishing feature of the sarcoma cells is their lack of uniformit)' in size, form, and color. The chief varieties of the sarcoma cells are the round, fusiform, mye- loid, and pigmented. In malignant tumors of the epiblast and hypoblast the cells are characterized by their immature or embryonic development, and they bear a very close resemblance to the cellular elements which are found in these layers of the germinal disk. Here, also, the cells lack uniformity in size and shape. They vary in size from 1-600 to 1-1500 of an inch in diameter, and are polygonal, round, oval, caudate, and fusiform in shape, while the nuclei of the epithelioma and carcinoma cells, as in the sarcoma cells, are multiple. At one time the poly- morphic character of the cells in epithelial tumors was supposed to be diagnostic of carcinoma, but it is now thought to be the result of rapid cell-proliferation and pressure. Nevertheless, the polymorphic char- acter of the cells and the large multiple nuclei, though they cannot be considered as positively diagnostic of a malignant growth, yet they cast suspicion of malignancy upon all neoplasms in which they are found. Growth. — Tumor-cells multiply, like their prototypes, the normal cells, by a process of indirect division, or segmentation, known as karyokinesis. Nearly all the fixed-tissue cells of the higher type mul- tiply in this manner. Growth in benign tumors is, as a rule, much slower than in the malignant form. A fibroma may require years to attain the size of a man's fist, but a malignant growth may reach the same dimensions in a few months. Cell-proliferation is very active in the malignant tumors, which results in rapid growth and defective development of the cellular elements. The kinetic process, as de- scribed by Strassburger, consists of three stages. During the first stage, or Prophase, the nuclear chromatin arrangA itself in the form of an oval mass. In the second stage, or Metaphase, the nucleus elon- 29 434 SURGERY OF THE FACE, MOUTH, AND JAWS. gates or becomes barrel-form, with a suggestion of equatorial division. During the last stage, or Anaphase, the nucleus and protoplasm are divided into two symmetrical halves, and separate, thus completing the process of segmentation. (See Figs. 55, 56, 57, 58.) Segmenta- tion of the nucleus without division of the protoplasm results in the formation of multinuclear and giant cells. Such imperfect karyo- kinesis is frequently found in the cellular elements of malignant neo- plasms. In the study of the kinetic process in malignant tumors, pathologists have discovered that the same phases are passed through as in the formation of normal tissues, with the exception that com- plete cell-dififerentiation is seldom reached in this form of tumor. Character, — Clinically all neoplasms are divided into three classes, viz: Benign, malignant, and suspicions. The class to which each belongs is determined by the character of the tissue which com- poses them, and the stage of development of the cellular elements. The more nearly a tumor approaches to normal tissue of the class from which it originated, the greater are the chances that it will prove benign; while, on the other hand, the more nearly the tissue and cells simulate an embryonic development, the greater is the liability that the tumor will be malignant. The suspicious tumors are those which do not belong strictly to the benign or malignant forms, but contain elements of both — the mixed tumors — or which are liable to take on active cell-proliferation of an embryonic character later in life, as the result of irritation. Certain forms of tumors may remain benign in character for years, when suddenly they take on active growth or cell-proliferation, and assume a malignant type. This is particularly true of papilloma and adenoma. Senn believes that this sudden change in the clinical be- havior of tumors is not an evidence of the semi-malignant nature of the growth, but that it was either malignant from its incipiency, or that it has undergone changes which give it a malignant character. The most marked clinical features which distinguish the benign from the malignant tumors are: First, a benign tumor never extends to other tissue than that from which it had its origin, while all malig- nant tumors extend to and involve other tissues than those from which its matrix was derived. For instance, a benign epithelial growth is always confined to the epithelial structures of the epiblast or the hypoblast, while a malignant epithelial tumor would involve the tissues in its neighborhood irrespective of their character or their ori- gin. Second, a malignant tumor has a tendency, which is made mani- fest early in its histor}', to involve the lymphatic glands, beginning with those which are most closely associated with the particular loca- tion of the tumor, and extending through the lymph-channels to others farther removed. These two features have been regarded for a TUMORS. 435 long time as the most reliable clinical evidence of the malignant char- acter of tumors. The manifestation of these evidences, however, par- ticularly the latter, comes too late to prove of value from the stand- point of effecting a radical cure. When extension to and involvement of surrounding tissues has become very marked, or the lymphatics are implicated, there is little hope of a radical cure of the disease. The character of the tumor can be diagnosed in most cases by the microscope, and yet, as we have already seen, there are certain malig- nant tumors which have a cellular structure in their early stages, so closely resembling the embryonic cells of the various germinal layers from which they spring, that it is difficult to distinguish between them. Consequently, every tumor which cannot be satisfactorily diagnosed to be a benign growth, should be classed as malignant, and immedi- ately extirpated as the only safe method of dealing with it. Waiting for positive evidence of malignant character before recommending a radical operation is foolhardy in the extreme, for when positive evi- dence is at hand, it may be too late to avert a fatal termination of the disease. Classification. — Tumors are now usually classified from two standpoints: First, from their origin and histologic structure, and second, from the stage of development of the cells composing the tumor-matrix. The germinal layers from which the neoplasms have their origin indicate the type of the growth, while the stage of arrested development of the cellular elements of the matrix will indicate the character of the tumor. Tumors of highly organized tissue represent the benign growths. Those approaching embryonic conditions of tissue represent the malignant growths. The first systematic classifi- cation of tumors was that made by Virchow^ in which he made the attempt to arrange all tumors according to their histologic structure. Virchow's Classification of Tumors. 1. Histioid; 2. Organoid; 3. Granulomata; 4. Teratoid; 5. Combination tumors ; 6. Extravasation and exudation tumors. 7. Retention cysts. This classification, in view of our present knowledge of the origin and cause of certain tumors, seems very imperfect indeed. All tumors composed of one kind of cells Virchow classed as "histioid tumors." Klebs maintains that a pure histioid tumor is only found in very small epitheliomas, sarcomas, and in angeiomas. As "organoid tumors" he classed all those growths which are composed 436 SURGERY OF THE FACE, MOUTH, AND JAWS. of several kinds of cells arranged in definite and typical forms, repre- senting the structure of organs. Senn thinks this term is incorrect and misleading, for the reason that even the most perfectly developed adenoma, or any other form of tumor, for that matter, is devoid of physiologic function. Among the "granulomata" which are infec- tive inflammatory swellings, he includes carcinomata and sarcomata, but until it can be proved that these tumors are the result of microbic infection, they have no place with the granulomata. The '"teratoid" tumors include all those growths which are composed of a system of organs, like dermoid cysts, an extra digit or limb, or a fetus within a fetus. "Combination tumors" are those which are composed of two- or more kinds of tumor tissues. The "extravasation and exudatioa tumors" are the result of traumatism or inflammation, and should be classed with the granulomata and inflammatory swellings. "Reten- tion cysts" should also be classed by themselves, as they are in no sense neoplasms. Virchow also divided tumors into two general groups. One he denominated Homologous, and the other Heterologous. In the first group he included all tumors whose histologic structure closely re- sembles normal tissue, and reproduces the type of tissue of the organ or part in which they are located. In the second group he placed all growths which deviate in their histologic structure from the type of tissue from which the tumor had its origin. From the clinical standpoint all homologous tumors may be said to be benign, and, in a general way, all heterologous tumors may be classed as malignant. There are exceptions, however, to this rule. A chondroma is a heter- ologous tumor, but it is benign; while on the other hand malignant tumors sometimes, in their early stages, present a homologous struc- ture. Malignant tumors, however, are always heterologous in their structure. Cohnheim, as already stated, was the first to classify tumors ac- cording to their embryonic origin. The classification is, however, somewhat imperfect, as the myomata and neuromata should be classed with the tumors of the connective-tissue type. Cohnheim' s Classification of Tumors. ( Fibroma (Fibrous-tissue tumor). Lipoma (Fatty tumor). Myxoma (Mucoid tumor). I. Chondroma (Cartilaginous tumor). Connective-tissue ■{ Osteoma (Bony tumor). Type. Angeioma (Vascular tumor). Lymphangioma (Lymphatic-vessel tumor). Lymphoma (Lymphatic-gland tumor). ( Sarcoma (Embryonic connective-tissue tumor). 437 II. Epithelial Type. r III. Myomata. IV. Neuromata. 1 V. Teratomata. Epithelioma (Epithelial tumor of skin or mu- cous membrane). Onychoma (Horny tumor). Struma (Scrofulous tumor). Cystoma (Cystic tumor). Adenoma (Glandular tumor). Carcinoma (Embryonic epithelial-tissue tumor). (Involuntary-muscle Myoma laevi-eellulare tumor). Myoma stri-cellulare (Voluntary-muscle tu- mor). Neuroma (Nerve-tissue tumor). Glioma (Klebs). (Connective-tissue tumor of nerve and brain.) Teratoma (Virchow). (Tumors composed of various tissues or organs. Monstrosities.) Sutton, in his classification of tumors, makes the attempt to bring order out of confusion by following lines of classification similar to those employed in biology, and divides tumors into four groups, viz: First, connective-tissue tumors; second, epithelial tumors; third, der- moids; fourth, C3^sts. These he again subdivides into genera, species, and varieties, according to their histologic structure and character. This classification is a great improvement over those of Virchow^ or Cohnheim, by reason of the fact that it is based upon the origin and the character of the histologic structures which compose the tumors. Sutton's Classification of Tumors. j Lipomata. I Chondromata. Osteomata. Odontomata (tooth tumors). Fibromata. Myxomata. Gliomata (neuroglia tumors). Sarcomata. Myomata (muscle tumors). Neuromata (tumors on nerves). Angeiomata. i Lymphangeiomata. I. Group, Connective Tissue 438 SURGERY OF THE FACE, MOUTH, AND JAWS. II. Group, Epithelial Tissue. Papillomata j Skin warts. I Villous papillomata. I Intra-cystic warts. 1^ Psammomata (Meningeal tumors). Epithelioma (Epithelioma). Mammary. Sebaceous. Thyroid. Adenoma Carcinoma (cancer) Pituitary. Prostatic. Parotid. Hepatic. [ Mammary. Sebaceous. Thyroid. - Prostatic. Parotid. Pancreatic. (^ Hepatic. Renal. Ovarian. Testicular. Gastric. Intestinal. Fallopian. Uterine. Renal. Ovarian. Testicular. Gastric. Intestinal. Fallopian. Uterine. III. Group, Dermoids. i I Sequestration dermoids; Tumors from hidden surface epithelium. ) Tubulo-dermoids ; Tumors from obsolete fetal I canals. I Ovarian dermoids. ^ Dermoid patches. f Retention cysts. Tubulo-cj'Sts. Hydroceles. [ Gland cysts. f Diverticula. j Bursas. ""] Neural cysts. ( Parasites. Senn classifies tumors with special reference to their relationship to the various germinal layers, and the stage of arrested cell-develop- ment in the elements composing the tumor-matrix. Senn's Classification of Tumors. { Papilloma. I. Epiblastic and Hy- j Adenoma, poblastic Tumors, i Cystoma. 1^ Carcinoma. IV. Group, Cysts. Sub-group, Pseudo-cysts. 439 II. Mesoblastic Tumors. , III. Epiblastic, Hy- "] poblastic, and Mesoblastic Tu- mors. I Fibroma. Lipoma. Myxoma. Chondroma. Osteoma. Angeioma. Lymphangeioma. Lymphoma. Myomata Neuromata (Lsevi-cellulare ; Stri-cellulare). (Neuroma; MyeHnic; Amyelinic). GHoma (Klebs). Sarcoma. ]- Teratomata. IV. Swellings caused j by retention of [ physiologic se- | cretions. J Retention cysts. REVIEW. CHAPTER XLII. Give the definitions of tumor. What conditions are sometimes mistaken for neoplasms? How may inflammatory swellings be recognized? How recognize new growths? In what form of tumor is growth spontaneously arrested? Do malignant tumors ever resemble inflammatory swellings? What does this indicate? From what do neoplasms originate? What were Cohnheim's views? What are Senn's modifications? Name the germinal layers of the disk of Pander. What tissues and organs are developed from the epiblast? What tissues and organs are developed from the hypoblast? What tissues and organs are developed from the mesoblast? 440 SURGERY OF THE FACE, MOUTH, AND JAWS. With what peculiar function are cells endowed? Are cells of one variety ever changed into another variety? What becomes of the misplaced embryonic tissue? What does a tumor-matrix of congenital origin always represent? What governs the histologic structure of new growths? A tumor-matrix derived from the epiblast or hypoblast would produce what form of tumor? What form of tumor would be produced if derived from the mesoblast? The character of the tumor depends upon what condition in the tumor- matrix. What condition of cell-growth favors the development of benign tumors? What condition favors the development of malignant growths? What type of tumor would be developed from a matrix derived from the epiblast or hypoblast with cell-differentiation almost completed? What type, if cell-difTerentiation was arrested in its early stages? What type of tumors is developed from the mesoblast under like con- ditions? What resemblance is found between benign tumors and normal tissue? How are malignant tumors distinguished? What is the diflference between a sarcoma cell and an immature connective- tissue cell? What other conditions distinguish them? What are the distinguishing features of malignant tumors of the epiblast and hypoblast? What is the cause of the polymorphic character of the cells? What do they indicate as to the character of the tumors? How do tumor-cells multiply? By what term is the process known? What character of tumor is slowest in growth? In which is cell-proliferation most active? Name the stages of the kinetic process or cell-segmentation. Describe the process in the first stage — Prophase. Describe the process in the second stage — Metaphase. Describe the process in the third stage — Anaphase. How are giant cells formed? Is the kinetic process the same in the growth of malignant tumors as in normal tissue? How are tumors divided clinically? By what is their character determined? What are suspicious tumors? What forms of benign tumors sometimes take on a malignant character late in life? How is this explained? What are the clinical features which distinguish benign from malignant tumors? What are the chances of cure after the lymphatics have become involved? How may diagnosis be made of the character of the tumor? What course should be pursued when the tumor cannot be proved to be benign? From what two standpoints are tumors now classified? What form of tissue represents the benign growths? What form of tissue represents the malignant growths? How did Virchow classify them? TUMORS. 441 Name some of the objections to this method of classification. Into how many groups did Virchovv divide tumors? Name them. What is the character of all homologous tumors viewed from the clinical ■standpoint? What is the character of the heterologous tumors from the same stand- point? What are the objections to Cohnheim's classification? What is the method of classification adopted by Sutton? Into how many groups does he divide them? Name these groups. Upon what does he base the subdivision? How does Senn classify tumors? CHAPTER XLIII. TUMORS OF THE FACE, MOUTH, AND JAWS. Epithelial Tumors. The various forms of tumors which are most commonly found associated with the face, mouth, and jaws are : Epithelial Group, or Epiblastic and Hypoblastic Tumors. Connective-Tissue Group, or Mesoblastic Tumors. Composite Group, or Epiblastic, Hypoblastic, and Mesoblastic Tumors. Swellings resulting from retention of normal secretions. '] Papillomata. I Adenomata. I Cystomata. J Carcinomata. Fibromata. Chondromata. ' Osteomata. Angeiomata. Sarcomata. 1 Odontomata. 1 }- Retention Cysts. J In the consideration of the subject of tumors located in the region of the face, the foregoing order will be followed, for the reason that the student, it is hoped, will gain a better knowledge of the character and tendencies of such growths if they are studied in separate groups, and according to their classification, from the standpoint of their histo- genesis and morphology. The Epithelial group comprises all of those neoplasms which have their origin in the epiblast or hypoblast. In these tumors the epithelial elements predominate; in fact, they constitute the essential and distin- guishing morphologic forms. The functions of the epithelium are exceedingly varied in man and in animals of complex organization; in certain locations it acts as a protection; as, for instance, the epi- dermis; it also becomes modified into hair, nail, horn, or enamel; in others the epithelial cells extend into the connective tissue beneath, in the form of processes, to form secreting glands, some of which are 442 TUMORS OF THE FACE, MOUTH, AND JAWS. 443 simple; as, for instance, the tubular glands of the intestines; others are complex, such as the liver, kidneys, pancreas, mammse, and the sali- vary glands. But whether the gland is simple or complex, the under- lying principle of construction is the same (Sutton), and is character- ized by narrow canals lined with epithelial cells arranged in a definite order, the canals resting upon a connective-tissue groundwork, which is ramified with blood-vessels, lymphatics, and nerves. The canals, or "epithelial recesses," of a gland are known as acini. Each acinus either directly communicates with a free surface of the body by means of its own duct, as in the simple mucous and sebaceous glands; or through several main ducts, as in the complex structure of the mam- mae ; or by a common duct, as in the equally complex structures of the parotid gland and the pancreas. Sutton calls attention to three notable exceptions to this rule, viz: the thyroid glands, the pituitary bodies, and the ovaries. All other secreting glands possess means of direct communication vidth free surfaces of the body, and are therefore subject to infection from all forms of micro-organisms. All epithelial tumors are composed of two kinds of tissue, — epi- thelial cells and vascular connective tissue, the latter forming the stroma or framework in which the epithelial cells are imbedded (Zieg- ler) ; while the number, character, and arrangement of the cells indicate the variety of tumor and its benign or malignant tendencies. The general plan of construction of epithelial tumors is that of a simple gland, and this form is maintained throughout many phases of their development. The degree of resemblance, however, differs greatly in the various forms. The adenomata most nearly resemble the struc- ture of some particular glandular type. The tumors which are farthest removed from this regularity in structure are the epitheliomata and the carcinomata. In these the epithelial cells are arranged in "compact, irregular masses," — "cell nests," — while in the adenomata the tendency is to a regular arrangement, the cells lining the inner wall of the alveoli and leaving an open space or lumen which corresponds to the saccule or acinus of a gland. It has already been intimated, in the preceding chapter, that tumors which in their structure closely resemble the nor- mal tissues of the part in which they are located are benign, and that tumors of an opposite character are malignant, or, to state it more correctly, the nearer the cells which give special character to the tumor approach complete differentiation the more certain are they to be innocent; while, on the other hand, the more nearly these cells ap- proach an embryonic condition of development the greater the cer- tainty that they are malignant. Epithelial tumors are developed by a multiplication of the epi- thelial cells. These are imbedded in the connective tissue, which is also undergoing multiplication of its cellular elements. This multi- 444 SURGERY OF THE FACE, MOUTH, AND JAWS. plication of cells may be, in certain forms of tumors, in the line, ap- parently, of a normal development of tissue, but in abnormal numbers, as when located in the papillary layer of the skin or mucous membrane, and resulting in the formation of papillomata; or the new formation may exhibit a structure resembling that of glandular tissue, and result in the formation of adenomata; in others the structural arrangement may very imperfectly represent glandular tissue, exhibiting only the earliest stages of gland formation; or the epithelial cells may be gathered into "irregular, compact masses," with a tendency to unlim- ited growth, as in carcinoma. In the epithelial type of tumor, especially in carcinoma, the epi- thelial cells lie in close contact with one another, and are seemingly united by a cement substance, or are continuous with one another (Warren). These "cell nests" are not directly supplied with blood- vessels. The connective-tissue framework or stroma, which is ar- ranged in the form of alveoli, contains the blood-vessels. The epi- thelial cells lie within the alveoli, and are sometimes so arranged as to give the appearance of a "bird's nest." The absence of tissue between the cells is characteristic of epithelial tumors (Warren), and forms a diagnostic sign by which doubtful cases of carcinoma may be dififer- entiated from alveolar sarcoma. In alveolar sarcoma the cells resemble those of carcinoma, but a close inspection reveals the fact that they are separated by a delicate connective-tissue framework or reticulum. Papillomata. Definition. — Papilloma (Lat. Papilla, a nipple; Gr. o/j.a, a tumor). A term employed to include corns, warts, horns, and certain nevi. A papilloma is a growth on the skin or mucous membrane, based upon or resembling a normal papilla. The papillomata are epithelial growths occurring upon the cuta- neous or mucous surfaces of the body, and are benign in character. These formations are generally considered as occup)dng a position midway between inflammatory swellings and true tumors, though some authors class them among the fibromata. Morphologically, the papillomata belong to the class of tumors which arise from the epiblast and hypoblast, — the epithelial group. They are essentially composed of epithelial cells, but the framework or stroma is furnished by the underlying connective tissue, conse- quently they contain elements which are derived from the mesoblast. All epithelial tumors contain more or less connective tissue as stroma, and, strictly speaking, are therefore mixed tumors, though they are not generally classed as such. The new tissue developed from the germinal layers in combination is never uniform in quantity; one or the other element predominates, thus giving diflerent histologic characters to TUMORS OF THE FACE, MOUTH, AND JAWS. 445 the neoplasms. This has made it somewhat difficult to determine to which group they belong, and has therefore caused the confusion in the classification. Papillary formations are frequently found in tumors which do not belong to this class of new growths; hence Virchow, Rokitansky, and others have objected to classifying the papillomata as a distinct type of tumor. Virchow named them "fibroma papillare." Warren places them among the epithelial neoplasms. Sutton and Senn both class them as epiblastic and hypoblastic tumors. In a majority of those tumors which can be classed, morpho- logically, as papillomata, the epithelial elements predominate and give character to the growth ; while in others in which the fibrous elements are in excess this circumstance may be considered as an accidental feature, due to the close relationship existing between the epithelial structures and the underlying connective tissue. In papilloma the essential part of the tumor is composed of epi- thelial cells, while the stroma or fibrous element is derived from the connective tissue, and contains the vascular supply. (Fig. 179.) The type of papilloma found upon the skin and in connection with the mu- cous membrane of the mouth, tongue, palate, etc., consists of a papilla, with a vascular connective-tissue base, covered with epithelial cells. They may be defined as excrescences from the epithelium of the skin and mucous surfaces. Their blood-supply varies greatly, but in cer- tain forms associated with the mucous membrane it is often very con- siderable. Usually the epithelium covers a single papilla or villus, but occasionally it extends over several, forming smooth plaques. The papillomata appear in two forms, — the hard and the soft. The hard form is the variety commonly located upon the skin and mucous membrane, and generally designated by the term Verruca (an excrescence) or warts. The soft form is most frequently associated with the mucous membrane of the bladder, stomach, duodenum, and colon (Birch-Hirschfeld), and also of the uterus (Warren). Growths of this character are sometimes found springing from the meninges of the brain, and may grow into the venous sinuses (Klebs). Sutton divides the papillomata into four species: warts, villous papillomata, intracystic warts, and psammomata. The difference in this classification from that generally followed is that of adding intra- cystic warts or papillomata, a rare variety sometimes found in mam- mary cysts, and of making separate species of those soft villous papil- lomata found in connection with the pelvis of the kidneys and the bladder, and of the epithelial bodies found in the membranes of the brain and the spinal cord, the psammomata. Senn classes warts with the condylomata and molluscum con- tagiosuni, which are inflammatory swellings of infective origin. 446 SURGERY OF THE FACE, MOUTH, AND JAWS. Hard papillomata of the skin, or skin warts, are the most common variety, and they are simply overgrown or hypertrophied papillse. They may occur singly or in groups, and unless irritated are rarely painful. The most common locations are the hands, feet, face, scalp, neck, and genitals. (Hyde.) They may be congenital or acquired. They are exceedingly erratic in their development and disappearance, their growth being sometimes slow, sometimes rapid; they may persist for years, or disappear suddenly, without apparent cause. In form they may be sessile or pedunculated, fiat or pointed, smooth or covered with secondar}' processes presenting a mulberry- or cauliflower-like Fig, 179. PAPILLOMA OF THl' SkiN (W appearance. In color they may be like the skin or pigmented; in some cases mottled with black. In size they may vary from a pin-head to a walnut, or even attain the size of the closed fist. They some- times bleed and ulcerate when irritated, and occasionally give off a very offensive odor. McCarthy reported a case (Sutton) of a man seventy-six years old having a tumor which sprang from the cheek and attained the size of half an orange, and completely covered the right eye. (Fig. 180.) Sutton reports a similar case of a woman forty years of age, with the tumor growing from the skin of the left temple, and another of a man thirty-six years of age, in whom the tumor was situated in the center of the pubic arch. This was as large as the closed fist, of the color of a TUMORS OF THE FACE, MOUTH, AND JAWS. 447 cock's comb, and emitted an abominable odor. The inguinal glands were enlarged upon both sides, but after the removal of the tumor the enlargement disappeared. Senn thinks papillomata of such size are never individual growths, but that they are produced by a confluence of several tumors. The hard form of papilloma is also found in connection with the mucous membrane of the lips, cheeks, tongue, _hard and soft palates, uvula, pharynx, larynx, and nasal cavit)', and also of the urethra, labia, vagina, cervix uteri, and bladder. Fig. iSo. Papilloma— Wart— Growing from the Skin of the Cheek and Obscuring the Eye. (McCarthy, after Sutton.) Papilloma of the mucous membrane of the mouth bears a close resemblance to the ordinary seed wart, and is of more frequent occur- rence than is commonly supposed; at least this is the observation of the writer, who has had a large field for clinical observation of the diseases of the mouth, and has found many opportunities for removing such growths. The most common locations are the lower lip, the soft palate, and tongue, and they appear in both the sessile and pedun- culated forms. Papillomata of the larynx are the most common of all the tumors of this region, comprising about 75 per cent. (Bos- 44^^ SURGERY OF THE FACE, MOUTH, AND JAWS. worth.) Butlin says they ''are among the more common of the inno- cent tumors which affect the tongue." Another form of papilloma is occasionally observed upon the gums, the hard palate, and the tongue, in which the papillse are greatly elongated, and the base of the tumor is of a dirty-white hue. Sir William Fergusson first described the disease in the London Lancet, September 6, 1862, the case occurring in the lower jaw of a man of eighty years. Salter describes the same case, and says the tumor was "a curious white mass, consisting of coarse detached fibers ; in fact, it was a mass of papillEe, many of them an inch long, and similar in shape to the fili- form papillae of the tongue; their surface was shreddy and broken; among these elongated processes were a few rounded eminences like fungiform papillae, and these had a smooth, unbroken surface." A similar case occurring in the hospital practice of Mr. Cock, of Guy's Hospital, and reported by Salter, was located upon the right side of the hard palate, and of the size of a "split chestnut;" had been growing about eight months. Tumors of this character seem to possess a tendency toward malignancy. Papillomata of the tongue are of frequent occurrence. They are usually located upon the dorsum of that organ, and are, in all prob- ability, caused by hypertrophy of natural papillae. They are not lim- ited, however, to the papillary area, but may have their seat upon the under side of the tongue, where the surface is quite smooth. (Butlin.) They appear as "small white tufts," usually upon a sessile base. Papillomata may appear at any time of life. Butlin mentions a case occurring in an infant ten months old. The disease occurs most frequently, however, in the later years of life, between sixty and seventy years of age (Watson), and oftener in men than in women. Diagnosis.- — The diagnosis of papilloma of the skin is in most in- stances one of little or no difificulty. Papillomatous growths, however, upon the mucous membrane of the mouth and tongue must not be con- founded with venereal warts — condyloma — nor with epithelioma, as- errors of this character might be productive of serious consequences. In children and youths, condyloma is the only afTection with which it can be confounded, as epithelioma is not a disease of early life. In adults, especially men, there is danger that the more serious form of epithelial tumor may be diagnosed as papilloma. This would be an exceedingly grave error, endangering the life of the patient. The diagnosis in the latter period of life becomes still more diffi- cult, on account of the tendency at this period of the simple form of the disease being transformed into the malignant type. Treatment. — The treatment of papillomata is ablation with the knife or scissors and thorough cauterization of the base, either withi TUMOKS OF THE FACE, xMOUTH, ANIJ JAWS. 449 Stick nitrate of silver, clilorid of zinc, or the galvano-cautery. Various other methods are recommended for their removal, such as the applica- tion of A'ienna paste, ligation, and galvano-puncture. The treatment of the disease when occurring late in life should be more heroic. A considerable portion of the surrounding tissue should be removed with the tumor, as by such treatment the dangers of a re- currence, should the growth prove to possess malignant tendencies, would be much less than though a minimum amount of tissue had been scarified. Besides this, the surgeon would have the satisfaction of feel- ing that if he had made an error in his diagnosis, it was upon the side of the best interests of the patient. Fig. i8i. Cutaneous Horn. Madam Dimanche. (After Sutton.) Cornu Cutaneum — (Horny tumors growing from the skin). — Another variety of papillomata, though one rarely seen, are the cutane- ous Iiorns. In this form of papilloma the tumor is composed almost exclu- sively of epithelial cells from the horny layer of the skin, which ordinar- ily, after serving their purpose, are desquamated, but which for some reason remain attached to the tumor-matrix, gradually increasing until they form projections or horns of various lengths, from ^ inch to 12 or more inches. It is possible that the matrix of the cutaneous horn furnishes a cement substance (Senn) which fixes the epithelial cells, and thus prevents their removal by desquamation. These tumors have their origin in sebaceous glands, warts, cicatri- 30 450 SURGERY OF THE FACE, MOUTH, AND JAWS. cial tissue, and nails. They are most frequently located upon the scalp, temple, forehead, eyelid, nose, lip, cheek, and shoulder, and upon vari- ous other portions of the body. One of the most remarkable cases of cutaneous horns — sebaceous — is that of Madam Dimanche, who had a long horn growing from the forehead, and another smaller one from the right cheek (Sutton) ; a wax cast of whose face is preserved in the Fig. 182. Horns Growing from the Scar Burn. (Cruvielhit museum of the Royal College of Surgeons, England. (Fig. 181.) A very remarkable cicatricial horn arising from the palmar surface of the hand following a severe burn, and which reached such an enormous size that amputation became necessary, was reported by Cruvielhier. (Fig. 182.) Mr. Edwards, of London, also reported a similar one originating in a burn which occurred sixty-five years previously (Sut- ton). The tumors in both of the latter cases were multiple. Wart TUMORS OF THE FACE, MOUTH, AND JAWS. 45! horns are prone to degeneration at their base, and in elderly persons they may not infrequently terminate in epithelioma. To determine the origin of cutaneous horns, Sutton divides them longitudinally. The existence of a cyst at the base proves them to be of sebaceous origin; its absence, of warty origin. The nail horns need no description in these pages, as they are only met with in connection with the fingers and toes. Treatment.- — Cutaneous horns, as a rule, are not very firmly at- tached to the skin, and are usually easily detached with the fingers. When too firmly adherent for removal by this means, they can be ex- cised. Occasionally amputation of the member upon which it grows may be necessary. After removal of the growth, the base should be thoroughly cauterized to destroy any remnants of the tumor which might remain, and thus prevent a recurrence. When epithelioma at- tacks the base of the horn, early and heroic treatment is demanded. REVIEW. CHAPTER XLIII. Name the tumors of the Epithelial group most often associated with the face, mouth, and jaws. Name those of the Connective-tissue group. Name those of the Composite group. What are those tumors called which result from the retention of normal se- cretions? What is the origin of the neoplasms comprised in the epithelial group? What form of cells predominate in these tumors? Describe the functions of the epithelium. What three glands do not have direct communication with free surfaces of the body? What does this direct communication with the surface of the body of the other glands subject them to? Of what two kinds of tissue are epithelial tumors composed? How do these tissues indicate the benign or malignant character of the neoplasm? What is the general plan of construction of the epithelial tumors? Which tumors most nearly resemble glandular structures? Which have the least resemblance? What is the character of the arrangement of the cells in the epitheliomata and carcinomata? How do the adenomata differ from this? What are the stages of cell difTerentiation which indicate the innocent or malignant character of these neoplasms? How are the epithelial tumors developed? What are the conditions of cell-multiplication which result in the forma- tion of these various forms of epithelial tumors? 452 SURGERY OF THE FACE, MOUTH, AND JAWS. What is the arrangement of the cells and the stroma in carcinoma? How may carcinoma be distinguished from alveolar sarcoma? Give the definition of Papilloma. Where are these tumors found, and what is their character? How do some authorities class the papillomata? Where do they belong, morphologically? Of what are they composed? What are some of the conditions which have led to confusion in the classi- fication of the epithelial tumors? Are papillary formations found in other locations than upon the skin and mucous membrane? What cell elements predominate in the true papillomata? Of what does the typical papilloma of the mucous membrane of the mouth, tongue, palate, etc., consist? In what forms do the papillomata appear? Where are the hard forms commonly located? What term is applied to them? Where is the soft form generally located? What is Sutton's classification of the papillomata? How does Senn class the warts? Which are the most common forms of papilloma, the hard or the soft varieties? What is the most common location of warts? Describe their peculiar characteristics. Describe their form, color, etc. Upon what portions of the mucous membrane are they found? What is their appearance? Where are they most commonly located? In what other locations connected with the mouth are they found? What other form of papilloma is occasionally found upon the gums, hard palate, and tongue? What seems to be the tendency of tumors of this type? Are papillomata of the tongue frequent? What are the most common locations? What is the appearance? At what age do papillomata most frequently occur? In which sex are they most common? Is there difficulty in the diagnosis? What afifections of the mucous membrane should not be confounded with papilloma? When is the diagnosis most difficult? Describe the usual treatment. What should be the character of the treatment in cases occurring late in life? What are the cornu cutaneum? Describe these growths. Where do these tumors have their origin? What is the most common location? What is the tendency of wart horns? How may their origin be determined? What is the treatment usually adopted? When epithelioma attacks the base, what should be the treatment? CHAPTER XLIV. EPITHELIAL TU.MORS (Continued). Adenomata. Definition. — Adenoma (Gr. aor,-^, gland, and (./(«, tumor). An adenoma is a tumor that has developed from a gland, or is construcud after the type of a secreting gland. An adenoma is a true neoplasm, and should not be confounded with retention cysts, or with glands enlarged by overgrowth, overwork, or chronic inflammation, for these conditions are in no sense new for- mations. Although we might on first thought be inclined from the definition of the term adenoma, to class all glandular enlargements in which there was an abnormal multiplication of the glandular elements, as adenomata, yet upon a consideration of the evident physiologic impotence of new growths to produce a normal gland-secretion (Ziegler), and the lack of anatomic relations with surrounding tissues, such a classification would be manifestly incorrect. Senn says, "In the strictest etiologic and pathologic sense, the term should be limited to glandular tumors containing adenomatous tissue produced from a tumor-matrix independently of the pre-existing glandular tissue." The adenomata are less distinctly defined in structure than most of the other neoplasms. The transitions between glandular hyperplasias and glandular tumors are manifold. The former are many times dis- tinguished with difficulty from certain inflammatory swellings, while the latter not infrequently present transitional forms which are almost identical with epithelioma. The anatomic and histologic structures of these growths are sometimes most difficult to define microscopically, on account not only of the transitional changes just referred to, but also because of other changes occurring within them and in the surrouiud- ing tissues, such as hemorrhage, edema, and various degenerative metamorphoses, like the fatty mucoid, colloid, fibroid, and hyaline (Figs. 183, 184); the formation of papillary and villous growths, and the development of cysts. Adenomata of the intestinal tract are ver}' prone to present a ma- lignant degeneration, or at least have the properties of malignant tu- mors (Councilman), viz: of infecting surrounding parts, and producing 453 454 surgery of the face, mouth, and jaws. Fig. 183. Hyaline (letjeueration. Hyalink Degknek Inflammatory tissue. D OF THE Neck. Fig. 184. Fibroid Degener.ation — Mamm.-e. X 50. EPITHELIAL TU.MORS. 455 metastases. When tlie disease is located in the stomach or intestines, the several coats are successively attacked, often resulting in perfora- tion. Ziegler applied the term adenoma destruens to this variety of adenomata. The true adenomata can generally be distinguished from the glan- dular hyperplasias by certain well-marked signs of consistence, color, and structure, as compared with the surrounding tissue. These tumors are of themselves benign growths, but the tendency to pass into cancerous formation must be constantly borne in mind. Pure aden- oma is a rare affection. The structural peculiarity of an adenoma is the presence of epithe- lial cell-elements which are arranged after the order of secreting glands, and supported by a connective-tissue stroma. (Fig. 185.) In Fig. 185. Adenoma (Polypus) of the Rectu.m, showing the Gl (After J. D. Hamilton.) a, gland lined by columnar epithelium ; d, stroma of the tun some forms of adenoma the epithelial element predominates, while in others the connective tissue is largely in excess. Most of these neo- plasms are mixed tumors, having other elements, — fibrous, myxoma- tous, sarcomatous, carcinomatous, etc., — in combination with the glandular structure. Tumors formed in this manner are designated as fibro-adenoma, mj'xo-adenoma, etc. Fig. 186 shows the histologic structure of fibro-adenoma. Adenomata occur as congenital tumors; as developments of early life, and they occasionally occur during any period of adult life. They are found in such tissues as the breast, the skin, the mucous membrane, the kidneys, the liver, the thyroid and parotid glands. Although aden- oma is not a common form of tumor, it has a wide distribution, beins: 456 SURGERY OF THE FACE, MOUTH, AND JAWS. found in nearly all portions of the body which have had their origin in the epiblastic and hypoblastic layers of the germinal disk. Inasmuch as adenomata are found in all of the glandular structures of the body,, it should be noticed, as a marked peculiarity, that the cells which com- pose these neoplasms closely resemble the individual structure of the gland or duct with which they are associated. The adenomata usually appear as knot-like growths in the sub- stance of glands, in glandular epithelium, or epidermic tissues (Zieg- ler); their most common seat being such glands as the mamma, the Fibroadenoma. X 50. ovary, the parotid, the thyroid, and the liver; also in the glands of the mucous membrane of the rectum, the intestines, and the uterus (Sut- ton). They may be sessile or pedunculated, the form being governed by their character and location. The development of adenoma is not necessarily confined to pre- existing glandular structures, as they may be formed in locations where glands do not normally exist. The explanation of the origin of the tumors in such locations is to be found in the displacement and isola- tion of embryonic cells during fetal life, or in the formation of a "tumor EriTHELIAL TUMORS. 457 matrix" of embryonic cells within a supernumerary or accessory gland. (Senn.) The glandular tumors vary considerably in size, ranging from a pea-like nodule to as large as a man's head, in locations like the female breast; while cysto-adenoma of the ovaries weighing thirty to forty pounds are not uncommon. The adenomata are developed in two forms: the ac/;(0(/.f and the tubular. Acinous adenoma simulates the structure of the conglomer- ate glands. The stroma varies in amount. If the tumor is hard, the Fig. 187. \\ " »3 J nV x9 ^ "s^* m J j > -• t ^ Section of an Adenoma from a Child's Rectuii. Highly Magnified. (After Sutton.) Stroma is abundant; if soft, it is scanty. The blood-vessels are located in the stroma, and each lobule or tubule is supplied from these with a capillary net-work of vessels, while the lobules or tubules are lined with flat epithelial cells. These tumors are usually associated with the con- glomerate glands. Tubular adenoma closely resembles the simple tubular glands. The epithelial cells are arranged in single or stratified layers within the tubule, while an open space is left in the center. This form springs from mucous membranes which have glands of the tubular form. It is most commonly associated with glands of this construction located in the intestinal canal, and especially in the rectum. (Fig. 187.) Causes. — The causes may be divided into predisposing and excit- 458 SURGERY OF THE FACE, MOUTH, AND JAWS. The predisposing or essential cause is the presence of a tumor- matrix of embryonic cells which have been misplaced, and isolated during fetal development. The tumor-matrix, however, may remain indefinitely in a quiescent and undeveloped state, until stimulated to activity by some abnormal condition of its surroundings, or by a direct injury. The exciting or active causes of their development are traumatic injuries, irritation of various forms, and acute or chronic inflamma- tions. Organs which are the seat of periodic congestions, like the mamma, the ovary, the uterus, and the prpstate gland, are the most common location of these tumors; while in the mucous membranes which are most liable to catarrhal affections, like the nasal passages and the rectum, these neoplasms are of common occurrence. Prognosis. — The prognosis of true adenoma depends principally upon the location in which it is developed. It is benign in its char- acter, and when completely removed does not return. It differs from the malignant tumors in that it does not infect the lymph-glands in its neighborhood, neither does it cause metastatic deposits. It frequently attains an enormous size, and when located in the ovaries, or in the thyroid glands, sometimes causes a fatal termination. Death in these cases is caused by mechanical complications, usually of pressure upon important viscera or vital organs. Adenoma is inclined to undergo degenerative changes, particularly hyaline, colloid, cystic, and fatty de- generation. It has also a tendency in the later years of life to take on malignant transformations. Adenoma of the Skin. — In adenomata of the skin, the tumors are found associated with the szveat or sudoriparous glands and the sebaceous glands. (Fig. 188.) Adenoma of the sweat-glands is seen in various parts of the body, but most frequently upon the face. These tumors may vary in size from a pea to a walnut, or may even be as large as the fist. In appearance they are commonly small, soft tumors, with nodular surface and a dirty, grayish-white color. Generally they are circumscribed, but occasionally they form diffuse or ill-defined growths. The skin over them is at first but little changed, but later it is often ulcerated (Wagner), and they have been mistaken for angeio- mata. They are slow of growth, and are a somewhat rare form of neo- plasm. A cut section of such a growth discloses coils of dilated ducts, from which can be pressed degenerated epithelium (Warren). The growth of the tumor seems in some instances to take place from the deeper portion of the tubule of existing sweat-glands, while in others it seems to be quite independent of any glandular origin. Thierfelder observed a case in which the tumor had its origin in the diploe of the cranial bones, but commtmicated with the skin. This connection would point to the probability that it originated in the skin. EPITHELIAL TUMORS. 459 Adenoma of the sebaceous glands appears upon the face in the form of papules, which are usually of congenital origin (Warren), and form little, roundish, convex tumors, the size varying from that of a pin-head to that of a pea, often bright crimson in color. The small tumors assume the form of a sebaceous gland, but in the larger ones the glandular tubule (Senn) forms a convoluted mass. (Fig. 189.) Fig, iSS. CTioN OF Human Scalp, showing GLANDtu, (T, Charlers White,) StRICTI-RE AND HaIR. The nose is a favorite seat for the development of this form of tumor. Tumors found in this location were formerly called lipomata, but they are now known in many instances (Sutton) to be sebaceous adenomata. This form of adenoma is quite prone to ulcerate, and occasionally to calcify (Eve). Diagnosis. — In diagnosing adenoma of the skin, there is as a rule very little difficulty, for the especial features of the disease are well de- fined, and the growth always occurs in regions occupied by sudoripar- 460 SURGERY OF THE FACE, MOUTH, AND JAWS. ous or sebaceous glands. Tlie diseases which ma\' be mistaken for adenoma of the skin are epithehoma, molluscnm epitheliale, and hpoma. Prognosis. — The prognosis in uncompHcated adenoma of the skin is always favorable : recurrence after extirpation is rare. Treatment. — The treatment is surgical, and consists of the removal of the tumor. This is accomplished in most cases with ease, as these tumors are usuall}- encapsulated, and are readily shelled out or enu- cleated. Fig i8g Large Sebaceous Adenoma involving the Pinna. (Afier Sutton.) Adenoma of the Mucous Membrane. — Adenoma of the mucous membrane appears in two forms. One is confined to the mucosa or mucous membrane proper; the other involves the sub-mucosa, or the submucous connective tissue, and from this it extends to adjacent tis- sues and organs. The first variety is expressed in the form of polypoid growths, the structure of which closely simulates the glandular arrangement of the membrane from which it springs, the difference being that the glandu- lar elements are larger, more numerous, and less regular (Ziegler) than in the normal tissue. (Fig. 190.) This form Ziegler classes as glandu- lar hyperplasias. The second variety he designates as adenoma des- truens. This latter form also simulates the glandular structure of the mucous membrane, but differs from the other variety in its mode of de- velopment and its tendencies to involve surrounding tissues and cause metastases. The first variety is frequently associated with the Schneiderian mucous membrane in the form of pedunculated growths in the nasal EPITHELIAL TU.MORS. 461 passages and vault of the pharynx. These growtlis may be in the form ■of mucous or gelatinous polypi, or they may be true adenomata. (Fig. 191.) The majority of polypi are not true adenoid growths, but in- flammatory enlargements or hyperplasias of the glandular elements of the mucous membrane. The adenoid vegetations described by Meyer, Cohn, and others, are not of very frequent occurrence, but a condition of hyperplasia of the glandular elements of the pharyngeal tonsil, which is expressed in nodular enlargements or polypoid excrescences, is quite common. The true adenoid growths sometimes attain to con- siderable size. In the nasal passages they have been known to fill these passages and the adjacent sinuses, causing distention and facial deformity. Fig. 190. Cystic degeneration of the mucous glands, of the lining membrane of the nasal passages, and of the antrum of Highmore, is occasionally seen. This form of the disease, however, is more common in the an- trum than in the nose. Occasionally the glands are enlarged and mul- tiplied as in adenoma, resulting in adciio-inyxoiiia. The adenoid growths of the antrum not infrequently manifest malignant tendencies, ending in adeno-carcinoma. The malignancy of this form of tumor is equal to that of the most malignant type of carcinoma, and it is the opinion of the writer that many of the malignant growths of the antrum that are classed as carcinoma and epithelioma have their origin in 462 SURGERY OF THE FACE, MOUTH, AND JAWS. adenoid growths, associated with the hning mucous membrane of this; sinus. The destructive adenoma ("adenoma destruens") is a soft, mar- rowy tumor, taking the form of capillary or fungous outgrowths (Zieg- ler), or of an extensive thickening, and a slightly raised surface of the affected portion of the mucous membrane. The new-formed tissue shows a marked tendency toward degeneration in the formation of ulcerated surfaces. The ulcers appear with raised, "ranipart-like"' Fig. 191. Nasal Polypus— Myxomatous Tissue— showing Ciliated Epithelial Cells. X 5°. edges, and a soft, infiltrated base, and the surrounding tissue is fre- quently studded with nodular growths. This form is most frequently seen in the stomach and intestinal mucous membrane. Adenoma of the buccal mucous membrane rarely attains dimen- sions larger than a pea or a small bean, though occasionally it may reach a much larger size. They are generally true adenomata, and are most often seen upon the lower lip and cheeks, — rarely upon the upper lip. These tumors are of slow growth, and several years may elapse before they attain a size sufficient to cause inconvenience. Diagnosis and Symptoms. — Adenoma of the buccal mucous mem- brane appears as single, smooth or nodulated enlargements beneath the mucous membrane, firm and non-elastic to the touch, usually ses- sile, and but slightly adherent to the overlying membrane or to the tis- EPITHELIAL TUMOKS. 463 sues beneath, and generally encapsulated. They are not painful unless ulceration or cancerous degeneration takes place. The only promi- nent symptom in the benign form of the disease is one of incon- venience, occasioned by its size or location, or both. Adenoma of the Palate. — Adenoma is more frequent in the palate than in other portions of the oral cavity. The growths appear as smooth or nodulated tumors beneath the mucous membrane; in other Fig. 192. Adenoma — Pure— of Palate. X 40. respects they are like those found upon the lips and cheeks. They are located upon either side of the median line, and when they are of large size cause, as a first evidence of their presence, a slight nasal twang of the voice (Cohen). Later there is a gradually increasing mechanical difficulty in swallowing, at first of liquids only; later of all ingesta. Fig. 192 shows the histologic structure of a pure adenoma of the palate. Diagnosis and Symptoms. — The development of neoplasms and in- flammatory swellings in the velum palati gives rise to certain definite symptoms, viz: dysphasia, cough, difficulty of breathing, changes in the resonance of the voice, which acquires a peculiar nasal twang due to 464 SURGERY OF THE FACE, MOUTH, AND JAWS, the imperfect occlusion of the soft palate with the vault of the pharynx. Pain is rarely associated with the growth of these tumors, or with the dysphasia incident to their presence. Prognosis. — The prognosis of adenoma of the oral mucous mem- brane and of the palate is usually favorable. In the destructive variety of the affection the prognosis would be unfavorable, as metastases and Fig. 193. Wire Ecraseur. recurrence are likely to follow. In the benign form of the disease, operation gives good results, as the growths can be removed in their entirety. Treatment. — The treatment of adenoma of the palate consists of excision, evulsion, or constriction. The character of the operation should be governed by the pathologic tendencies of the growth, its shape, and its accessibility. Polypi of the nasal passages may be removed by the wire snare or ecraseur. (Figs. 193, 194.) The ma- EPITHELIAL TUMORS. 465 jority of these tumors are encapsulated, and are easily removed by a single or double incision through the mucous membrane. A smgle incision only is required for growths of small size; the double incisions which are made at right angles to each other, are necessary for the removal of the larger growths. The existing adhesions are then torn or dissected away, the tumor turned out of its capsule, and the wound closed with sutures. In the region of the palate hemorrhage from the posterior palatine artery may sometimes prove troublesome, but it can be controlled by a tampon, ice, the various hemostatics, or by the electro-thermal cautery. The after-treatment should consist of fre- quent irrigation of the mouth with antiseptic solutions. Adenoma of the Tongue is an exceedingly rare affection. Butlin in his work on "Diseases of the Tongue" considers it "so rare, that no general account can be written of it." Of the four cases which he mentions, two of them occurred in persons near middle life, the third in a girl of sixteen, and the fourth in a new-born babe which lived only sixteen hours; death being due to pressure of the growth upon the larynx, the tumor having developed in. the base of the tongue. In one the tumor was situated well back upon the dorsum of the tongue; in another it was located upon the under side of the tip of the tongue, but in the case of the girl the location of the growth was not mentioned. Rosenberg thinks adenoma of the tongue is very rare. Accord- ing to Thaon and Larabie, these tumors are really mixed epitheliomas. The microscope reveals a connective-tissue net-work or stroma which embraces the epithelial infiltration. In the early history of these growths the epithelial elements are in excess ; later the connective-tis- sue elements predominate, which in all probability accounts for the relative innocence of these neoplasms. Larabie advises, on account of the possibilities of these growths developing true carcinomatous ele- ments, early and free excision of the tumor. Diagnosis and Symptoms. — There are no diagnostic signs or symp- toms which are distinctive of adenoma of the tongue, and no means whereby an exact diagnosis can be made, except by removal of a portion of the tumor and subjecting it to a microscopic examination. Adenoma, fibroma, and lipoma are not readily distinguished from one another while in situ, and may therefore be easily mistaken one for the other. The symptoms which are common to enlarged glands and the various tumors which may be located upon the dorsum of the tongue are a sensation of a foreign body in the throat, irritation, cough, dyspnea, dysphagia, fatigue of the voice, and painful deglutition in those cases associated with inflammatory conditions of the glands or of the neoplasms. Prognosis. — The prognosis of adenoma of the tongue is good. 31 466 SURGERY OF THE FACE, MOUTH, AND JAWS. Early extirpation is demanded as a precaution against the develop- ment of malignant disease, and to relieve the local symptoms. Treatment. — The treatment consists of enucleation or excision of the tumor. The removal of a sufficient amount of the surrounding tissue to insure a complete extirpation should always be practiced in those tumors which arouse suspicion as to their malignant character. Adenoid tumors of the tongue are usually found situated well back upon the dorsum of the organ, which makes the operation somewhat difficult to perform. The removal of these growths is not essentially different from the operation in other locations of the oral cavity, as they are always found encapsulated and are easily enucleated. Before commencing the operation, the tongue should be secured by passing a strong ligature through the tip, the tongue being drawn well forward and held in that position during the operation. The jaws should be held apart by means of a mouth gag. Hemorrhage is sometimes troublesome from venous and capillary oozing, but this can usually be controlled by pressure over the bleeding surfaces with a piece of gauze and the finger. When the loss of tissue has not been too great to permit of this, the edges of the wound should be brought together with sutures. Antiseptic treatment of the wound and of the mouth should be carefully followed to prevent suppuration and secondary septic infection. Adenoma of the Salivary Glands. — Adenoma of the salivary glands is not a common affection, but when it does exist it is asso- ciated with the parotid gland. The submaxillary and the sublingual glands seem to be quite exempt from this form of tumor. Weber is of the opinion that even the parotid gland is very rarely the seat of true adenoma. Billroth does not think that true adenoma ever exists in the parotid gland, but that all adenoid growths located in this gland are mixed tumors, adeno-cystoma, adeno-chondroma, adeno- carcinoma, etc. Pure adenoma, however, has been found in the paro- tid gland. Warren describes a perfectly formed adenoma in the parotid gland of the size of a hen's egg, and quite soft in structure. In this respect it differed from the ordinary tumors found in this gland. Parotid adenoma most frequently occurs in youth and early adult life, — between the fifteenth and thirtieth years of age (Sutton). Diagnosis and Symptoms. — Adenoma of the parotid occurs as dis- tinctly encapsulated tumors. They are not painful, may arise in any part of the gland, are of slow growth, and rarely exceed a pigeon's egg in size. Positive diagnosis is difficult to make except by a micro- scopic examination after the operation. Cystic^ degeneration is common, and papillary excrescences often develop upon the cyst-walls and project into the tumor. Microscopic examination of these excrescences shows them to be composed of the EriTIIElUAL TUMORS. 467 same elements as the secreting tissue of the gland. These tumors have a strong resemblance to the adenomata found in the thyroid gland. Usually they are encapsulated, and can be readily enucleated with little or no permanent damage to the gland. Prognosis. — The prognosis is favorable in uncomplicated adenoma of the salivary glands. In adenoma with malignant tendencies it would be very unfavorable. In the latter case, early and complete extirpation of the entire gland is the only means of saving the life of the patient. Treatment. — In operating for the removal of adenoma of the parotid, the incisions should be made with especial reference to the preservation of Stenson's duct without mutilation, and with due regard to the location of the branches of the facial nerve. The pos- terior edge of the gland lies in close relation to the external carotid, superficial temporal, transverse facial, internal maxillary, and internal carotid arteries, the external jugular vein and its anastomosing sub- maxillary branch, and the internal jugular vein. In cutting down upon the tumor, a thin portion of the gland may be incised, and as a result salivary fistula may follow the operation. Usually, however, if Stenson's duct has not been injured, the discharge of saliva through the wound is only a temporary matter. The extirpation of the gland for the removal of malignant growths may require the ligation of the external carotid artery and of the exter- nal jugular vein. REVIEW. CHAPTER XLIV. Give the definition of adenoma. What is an adenoma? With what conditions should it not be confounded? What characteristics mark the difference between adenoma and these con- ditions? What is the distinction made by Senn? State the conditions which make it difficult to distinguish glandular hyper- plasias from glandular tumors. What is the tendency of adenoma of the intestinal tract? What term does Ziegler apply to this form of the disease? How may true adenoma be distinguished from glandular hyperplasias? What is the character of a true adenoma? Is this form common or rare? 400 SURGERY OF THE FACE, MOUTH, AND JAWS. What is the structural peculiarity of an adenoma? What is the character of most of these neoplasms? Name the most frequent tumor-elements with which they are combined. At what periods of life do the adenomata occur? In what tissues are they located? From which embryonic layers do they originate? What is a marked peculiarity in the structure of adenomata of the various glands of the body? How do the adenomata usually appear? In what glands are they most frequently found? What is their form? Are the adenomata confined to pre-existing glandular structures? If not, what is the explanation of their origin? What is the variation in the size of these tumors? State the number and names of the forms of adenomata. Describe the acinous form. With what form of glands are they usually associated? Describe the tubular form. With what form of glands are they most often associated? How are the causes divided? What are the predisposing causes? What are the exciting causes? In what organs and tissues are the exciting causes most liable to produce the development of adenoma? Upon what condition does the prognosis of true adenomata depend? Do the true adenomata recur if completely removed? In what respects do they differ from the malignant tumors? How may death occur from true adenomata? To what forms of degeneration are the adenomata subject? With what glands is adenoma of the skin associated? Describe adenoma of the sweat-glands. Are they always associated with the glands? Describe adenoma of the sebaceous glands. What feature of the face is a favorite location for their growth? What is the tendency of this form of tumor? In the diagnosis of adenoma of the skin, what disease may be mistaken for it? What is the prognosis? What is the character of the treatment? In how many forms does adenoma of the mucous membrane appear, and in what portions of the membrane are they located? How is the first variety expressed? How does the second variety differ from the first? With what special mucous membrane is the first variety often associated? What form do these growths assume? What is the character of the majority of the nasal polypi? What condition of the pharyngeal tonsil is common? Do adenomata of the nasal passages ever attain large dimensions? What form of degeneration sometimes occurs in the glands of the lining membrane of the antrum of Highmore? What other form of degeneration may take place in adenoma of the antrum? Describe the appearance of the "destructive adenomata." What is the usual character of adenomata of the buccal mucous membrane? EPITHELIAL TUMOKS. 469 Where are they generally located? What is the character of their growth? Give the diagnosis and symptoms. Describe adenoma of the palate, and its location. What is the first evidence of a large tumor in this location? Give the diagnosis and symptoms. What is the prognosis? Describe the surgical treatment. How may hemorrhage be controlled? What should be the after-treatment? Is adenoma of the tongue a common or a rare disease? What is the character of these growths? AVhat is the explanation of the relative innocency of these tumors? Give the diagnosis and symptoms. What is the prognosis? Describe the operation for their removal. When hemorrhage is troublesome, how may it be controlled? With which of the salivary glands is adenoma most frequently associated? Is the disease common? Which forms are most frequently associated with the parotid gland? Are pure adenomata found in the parotid gland? At what age do they most often occur? Give the diagnosis and symptoms. What form of degeneration is common in adenoma of the parotid? Of what are the papillary excrescences composed? What is the prognosis? In operations for the removal of adenoma of the parotid gland, what special anatomical parts are involved? With what reference should the incisions be made? What form of fistula may result from the operation? Is this likely to be permanent? In extirpation of the gland for malignant growths, what artery may it be necessary to ligate? CHAPTER XLV. CYSTOMATA. Definition. — Cyst (Gr. -/.uurtz, a pouch), a cavity containing fluid, and surrounded by a capsule. "A cyst is a cavity, either natural or newly-formed, filled with a material more or less fluid, or pulpaceous, and surrounded by an investing membrane or capsule, which separates it from the surround- ing tissues." Fig. iqs. Cysts may be divided into two groups: First, those which are formed by the dilatation of cavities already in existence — the natural cavities of the body — or which are formed by a tissue already present in the body, by softening or degeneration; and, second, those which are the result of new formations — neoplasms — which press apart the normal tissues and form cavities in locations where they did not pre- viously exist. (Fig. 195.) Virchow makes three divisions of the first group, according to the manner in which the filling of these cavities takes place, viz: Extravasation cysts, Exudation cysts. Retention cysts. 470 CYSTOMATA. 4/1 Senn would restrict the use of the term "cystoma" to those cystic tumors whose cyst-wall is produced from a matrix of misplaced em- bryonic cells, and whose contents are the product of tissue-prolifera- tion of the cells which line the cyst-wall. This excludes all other forms of cysts except those which have originated independently of pre-existing cavities or glandular structures, and which are in the strictest sense new formations. The cystomata are usually classed as formations belonging to the epiblastic and hypoblastic group of tumors. In a strictly histo- logic sense, only the cystic neoplasms should be placed in this group, but from a clinical standpoint all forms of cysts might be included in it. An examination of the cyst-wall shows the inner surface to be lined with epithelium or endothelium, according to its mode of origin. The epitheHal cysts arise from distention of epithelial cavities already in existence (Ziegler). A glandular cyst caused by the closure of its duct is an instance in point. The secretion which collects behind the obstruction dilates the gland, forming a cyst, which is filled with an altered secretion. These are termed cysts of retention, and are found associated in the oral cavity with the salivary and mucous glands. They are, however, more commonly seen in connection with the mammse, kidneys, uterus, intestines, and the skin. Endothelial cysts arise from distention of cavities in the con- nective tissue which had a previous existence, like tendon-sheaths, synovial sheaths, obstructed lymphatics, and old hernial sacs. These are exudation cysts. The contents consist usually of lymph. Another form of cyst is that which occurs in the substance of solid organs, by softening and disintegration (Ziegler) of defined portions. These are termed cysts of disintegration. A fourth species of cyst is that which is formed around a foreign body which has become lodged in the tissues, like a bullet, or a para- site, like a hydatid (Ziegler), and is the result of a new-tissue formation. The classification generally used by surgeons is one based upon the character of the contents of the cyst, viz: Serous cysts, fat cysts, blood cysts, mucous cysts, grumous cysts, etc. The extravasation cysts contain blood; the exudation cysts, serum; while the contents of the retention cysts would vary with the physiologic function of the glands with which they were associated. Cysts found in connection with the teeth are usually exudation cysts; those associated with the mucous membrane and salivai-y glands are retention cysts ; while those found in the bone are the results of new formations. The contents of a cyst are always inclosed in a capsule or investing membrane, the capsule being of the same structure in all essential particulars as that lining the original cavity from which tlie cyst had its origin; conse- quently it would vary with the character of the anatomical structure 472 SURGERY OF THE FACE, MOUTH, AND JAWS. of the tissue in which it was located. In cysts associated with glandu- lar structures there is usually a well-defined epithelial lining, and it is a generally accepted fact that in all cysts with a well-defined epithelial lining the cyst is not the result of a new formation. (Fig. 196.) This epithelial lining is subject to considerable change, as, for instance, when greatly distended, a glandular epithelium may resemble the lining of a serous cavity. It may also be lost, in great part, by fatty degeneration. The cyst membrane is made up of firm, fibrous connective tissue, which is always more dense than the surrounding soft tissue, but in some cases it is much better defined than in others. The firmness and density Fig. ig6. MuLTlLOCULAR CYSTOMA — GLANDULAR of the capsule renders it possible in some cases to enucleate the cyst in its entirety. Inflammator}' adhesions, however, often take place between the cyst-wall and the surrounding tissue, as a result of trauma or medication, which renders it difficult or impossible to enucleate it. In cysts formed in the bones an inner connective-tissue membrane is usually present, and may sometimes be dissected out. Cysts may be classed as either simple or compound. A simple cyst is one consisting of a single cavity. A compound cyst is composed of an aggregation of simple cysts, or of many cavities which communi- cate more or less freely with one another. A single cyst is spoken of as a unilocular cyst, and a compound cyst as a multilocular cyst. The small cysts which occur upon the mucous CVSTOMATA. 473 membrane of the cheeks or upon the tong;iie, and in connection with the ducts of the salivary glands, are examples of unilocular retention cysts, while those which occur in the body of the glands where the acini of the glands become distended and communicate with one an- other are illustrations of multilocular retention cysts. The simple and compound cysts are frequently found in connection with bones. They are occasionally met with in the jaws, and sometimes are associated with the teeth. The most common forms of cysts are those associated with some glandular organ in which a tumor has formed, cutting ofif a portion of the glandular acini in which the secretion accumulates, distending the individual sacculi or lobuli. Age seems to have little or no efifect upon the formation of cysts. They may develop at any age from infancy to senility, and they are sometimes congenital. It has been thought by certain authorities that puberty exerted an unfavorable influence over those organs con- nected with the genital apparatus in which a predisposition existed to cystic formation, on account of the increase in the circulation and growth of the parts at this period. Cysts, as a rule, are slow in growth, but retention cysts and ex- travasation cysts are sometimes very rapid in their formation, often attaining an enormous size in a short period of time. The size of cysts is exceedingly variable, ranging all the way from microscopic small- ness to gigantic dimensions. The material forming the contents of a cvst is also subject to a variety of changes. It seldom happens in a cyst of long standing that the character of the contents remains in an unchanged condition. In extravasation cysts the blood undergoes the various changes incident to blood extravasations. It is first con- verted into a coagulum, which gradually grows more firm and dense, while the coloring matter is deposited in the form of amorphous coloring materials and crystals. Occasionally the blood will remain fluid for a considerable length of time, and apparently unchanged in other respects. In serous cysts the liability to undergo change is very considerable, the most frequent form being that of colloid degenera- tion, by which the contents are converted into a more or less thick, honey-like fluid. Cholesterin and fatty crystals of great variety are frequently found in profusion, while calcareous formations are not uncommon. Calcareous formations may arise from calcification of clots of fibrin, or they may be the result of direct precipitation from the retained glandular secretions, as sometimes occurs in occluded salivary ducts. Fatty degeneration is frequently found in slight degree in the epithelium of cysts, but it is of no particular consequence. In the higher degrees of metamorphosis the epithelium is thrown ofT, and the contents of the cyst become streaked or uniformly grayish-yellow or yellow. The walls of the cyst may also suffer fatty degeneration. 474 SURGERY OF THE FACE, MOUTH, AND JAWS. The capsule or investing membrane is liable to considerable change in the course of time. The most common is that of an increase of the thickness of the membrane, though the reverse of this may occur under exceptional circumstances. Calcification and, according to some au- thorities, ossification even may take place in the cyst-walls. When calcification takes place it usually forms in isolated places which have no connection with one another, though they occasionally unite and convert the entire cyst-wall into a firm, calcareous capsule. Under such ciixumstances the blood-supply is cut off by the occlusion of the vessels, all further growth of the tumor is arrested, and it assumes the position of a foreign substance in the tissues. Destruction of the cyst membrane may also take place from inflammatory processes arising from traumatic injuries or inflamma- tion extending from surrounding tissues. An injury which caused an extravasation of blood into a cyst containing serous fluid might cause coagulation of the entire mass and result in its obliteration. Inflam- mation sometimes leads to suppuration, and the cyst would then be converted into a pus-sac, which would destroy the epithelial lining and eventually close the cavity by granulation. Upon this fact is based the treatment often adopted by surgeons of inducing an inflammation by injecting irritating substances like iodin, etc., into the cyst. Cysts may exist throughout a lifetime without producing any ill effects, vet their location and size may sometimes become a menace to life, as, for instance, when occurring in the neck, they may seriously interfere with the act of swallowing and with respiration. Cysts of the internal organs, when of large size, are the most dangerous to life, usually from the secondary disturbances which they induce in the organs of the abdomen and thorax, and by inflammatory processes ending in suppuration or other changes in the cyst itself; or rupture of the cyst and discharge of its contents into the peritoneal cavity. Peritonitis with a fatal termination has often resulted from the latter condition, on account of the highly irritating effect often possessed by the contents of such cysts. Spontaneous involution — a shrinking or shriveling — of the cyst, whereby the capsule becomes hard, dense, and rigid, accompanied by degeneration of the papillary growths of the internal surface, has been observed in the ovarian cysts of old women. Cysts of the Jaws and Teeth. — Cysts of the jaws which are found associated with the teeth may be classed imder two heads: First, those which are connected with the roots of fully-developed teeth; sec- ond, those associated with malposed teeth or those of abnormal devel- opment. Single cysts in the form of accumulations of serum or degenerated pus are frequently found in connection with the roots of devitalized CYSTOMATA. 475 teeth which, from septic conditions, have been the subjects of inflam- matory processes, usually of a subacute or chronic form, and which has resulted in necrosis or erosion of these apices. These cysts are always adherent to the apex of the root, the necrosed or eroded por- tion being inclosed in a sac, and when small enough to pass through the alveolus they are frequently found attached to the apex upon the extraction of the offending tooth. The size of these cysts varies con- siderably, and they are found associated with both jaws, but they never assume the character, and rarely the proportions, of the ordinary den- tigerous or tooth-bearing cyst. Diagjiosis. — This class of cystic tumor is always found located be- neath the periosteum, hence Magitot denominates them periosteal eysts. They vary in size from that of a pea to a marble, though they occa- sionally attain much larger dimensions. When of large size, they cause extensive resorption of the bone, considerable swelling and deformity, and if located in the superior maxilla they may simulate empyema of the maxillary sinus, and be mistaken for that disease, while in excep- tional cases the cyst may occupy the antrum and give rise to a true empyema. Heath says that in his experience large cysts, which cause more or less absorption of the outer wall of the maxilla, are very com- mon consequences of the retention of diseased teeth, but that they seem to give very little inconvenience to the patients, even though they may be so large as to produce a considerable deformity of the face. A case of this character is described by Heath in a woman forty years of age. The tumor was of two years' standing, and situated immediately above the incisor teeth, which were decayed to the mar- gin of the gum. The maxillary sinus had become secondarily involved, as was proved by passing a probe through the incision made above the incisor teeth for the evacuation of the fluid. A case somewhat similar, which came under the observation of the writer, was associated with a superior lateral incisor and involved the antrum. Fischer, as quoted by Heath, reported a case of a large cyst associated with the root of a superior posterior molar, in which he had the opportunity of making a post-mortem examination. After removing the external wall of the antrum, the cyst was found to be connected with the pericementum at the apex of one of the roots, and it filled the whole of the antrum with- out being connected with the lining mucous membrane. The cyst was composed of a perfectly closed serous sac, with a smooth inner surface, and contained a yellowish serous fluid. An example of a common form of cysts in the inferior maxilla associated with devitalized teeth occurred recently in the private prac- tice of the writer. Miss G., aged thirty-five, housekeeper, had a pain- less swelling of the right side of the lower jaw in the region of the bicuspid teeth. The swelling was confined to the outer surface of the 4/6 SURGERY OF THE FACE, MOUTH, AND JAWS. jaw, and extended from the cuspid tooth to the first molar; the gum over the tumor was purple in color and hard to the touch, except at one point near the center, where there was evidence of fluctuation. Both bicuspid teeth were devitalized, with a history of acute abscess occurring two or three years previously. Puncture of the tumor re- vealed a cyst containing a thick, straw-colored, tenacious fluid, in which were found glistening flakes of cholesterin. The cyst was evac- uated and explored, when it was discovered that the roots of both of the bicuspids were involved in the cyst, and that they were consid- erably roughened near their apices. On extracting the teeth, it was found that erosion had taken place at the apex in both of them. Another case, in which the cyst was located in the superior max- illa, may be mentioned as a rather uncommon type. Mrs. W., aged twenty-eight, a private patient, came in September, 1891, with a large swelling under the left ala of the nose, involving the lip and side of the face. The swelling was painless, and had been of rapid growth, the first evidence having been noticed only five daj'S before. On raising the lip, the gum was found to be considerably swollen, very red, the disturbance extending from the cuspid tooth forward to the median line. Fluctuation was discernible over the center of the swelling. The incisor and bicuspid teeth had all been removed some years before, on account of extensive caries and abscesses, with a previous history of swelling and discharge of a watery fluid at frequent intervals in the location of the left lateral incisor, twice repeated at short intervals after the extraction of the teeth. The case was treated by incision and a 10 per cent, solution of iodin in glycerol, with seemingly a speedy cure. About six months later she returned with a recurrence of the disease. This time a careful search was made for an unerupted tooth or a fragment of the root of a devitalized tooth, but nothing of the kind could be found. The cavity was then thoroughly curetted, under the belief that the original cyst-wall had not been destroj'ed when the tooth had been extracted, and that it still retained the power of exciting a serous exudation. After washing out the cavity, it was packed from day to day with borated gauze. At the end of a month the cavity had closed by granulations, and no further inconvenience had occurred after a period of nearly four years. The character of the fluid contained in cysts associated with the diseased roots of teeth is generally a dark straw-colored, gluey liquid, often containing flakes of cholesterin. Occasionally it is thick and ropy, or if inflammation has been recently present, the contents may be purulent. Tomes suggests that cystic disease of the lower jaw may not infrequently be associated as the initial cause of irritation with the roots of diseased teeth. When the disease is located in the lower jaw, it is generally the external plate of the alveolus which gives way under CVSTOMATA. 477 the pressure of the accumulating fluid. As resorption of the bone progresses, crepitation over the swelHng is discernible, and if sufficient time elapses the bone will become completely resorbed, while fluctu- ation may be detected through the membranous covering of the cyst. Spontaneous rupture of the tumor sometimes occurs, but this does not effect a cure, for as soon as the opening in the cyst-wall has healed the fluid reaccumulates. The history of this form of cysts, from a clinical standpoint, is one of painless expansion of the alveolus and surrounding bone, resorption of the bony wall, crepitation under pressure, evidence of fluctuation, bluish appearance of the gum immediately overlying the cyst. It may be located in the alveolar process of either jaw, but most commonly in the superior. Wedl is of the opinion that the growths are more commonly found anterior to the bicuspid teeth than behind them. Prognosis. — The prognosis is one of recurrence, unless a radical operation is performed. Beyond the deformity caused by the swell- ing and its progressive enlargement, it need give no anxiety as to its issue, for fatalities from this cause are unheard-of results. Treatment. — The treatment, to be effective, must be radical. The diseased tooth must be first extracted, after which the cyst should be opened and the thin external wall cut away with scissors or the bone forceps, and the cavity thoroughly curetted. The surgical engine and bone-cutting burs will serve an admirable purpose in this class of operations. Curetting the cavity without removing the tooth, or re- moving the tooth without curetting the cavity, are only half-way meas- ures, and will be followed, sooner or later, by a recurrence of the dis- ease. Simple draining of the cavity is likewise a futile proceeding, as are all attempts to evacuate the cyst through the pulp-canal. Failure to cure this form of cyst has many times been caused by lack of proper ap- preciation of these simple facts. The cavity, after it has been curetted, should be dressed by packing it with bichlorid or boric acid gauze, and the dressings changed once or twice each day until the process of healing by granulation at the bottom of the cavity has been estab- lished, when the gauze may be dispensed with, and the wound kept clean by frequent irrigation. The expanded condition of the bone will gradually disappear as the healing process goes on, and eventually the deformity will entirely pass away. 47^ SURGERY OF THE FACE, MOUTH, AND JAWS. REVIEW. CHAPTER XLV. What is the definition of a cyst? How are cysts divided? What are comprehended in the first group? What in the second? How did Virchow divide the first group? Upon what is the classification usually based by surgeons? What is an extravasation cyst? What is an exudation cyst? What is a retention cyst? What form of cysts is usually connected with the teeth? What are they called when associated with glands? What are they called when associated with bone? By what are the contents of a cyst inclosed? What is the character of this investing membrane? What is the character when associated with glandular structures? What does a well-defined epithelial lining indicate? What forms of degeneration may attack the investing membrane? Of what is the cyst membrane composed? Is it possible to enucleate the capsule? What conditions may render it impossible to enucleate it? How are cysts classed? What is a simple cyst? How does a compound cyst differ from a simple cyst? What other terms are applied to these forms of cysts? Give examples of unilocular retention cysts. Give illustration of multilocular retention cysts. Are simple and compound cysts found in connection with bone? Are they commonly associated with the jaws and teeth? What is the most common form of cyst? What effect does age have upon the formation of cysts? Are they ever congenital? Does puberty exert an unfavorable influence or predisposition to the forma- tion of cysts? What is the character of their growth? Are retention and extravasation cysts slow or rapid in their formation? What can you say of the size of cysts? What are the changes to which the cyst contents are liable? What change takes place in extravasation cysts? What in serous cysts? How do calcareous formations arise? How do they arise in retained glandular secretions? What changes may take place in the capsule of the cyst? Does complete calcification ever occur, and how? How may an injury cause obliteration of a cyst? How may inflammation produce the same result? What are the means sometimes adopted by surgeons to bring about this result? CVSTOMATA. 479 Under what conditions may cysts prove a menace to life? How may cysts of internal organs prove fatal? How are cysts of the jaws classed? What are included under the first head? What under the second? What forms of cysts are found in connection with devitalized teeth? What are the causes? What is the condition of the apices of the teeth under these conditions? To what is the cyst always adherent? What can you say of their size? Where are they located? What are the diagnostic signs? Do they ever involve the antrum? What is the character of the fluid contained in cysts associated with devi- talized teeth? When the disease is located in the lower jaw, which plate of the alveolus usuallj' gives way first? What is the clinical history of this form of cysts? Which jaw is the most frequent location of these cysts? What is Wedl's opinion as to their location? What is the prognosis? Do fatalities ever occur from this form of cysts? What must be the character of the treatment to be effective? Of what should this radical treatment consist? Are half-measures of any value? What will be the result of such measures? What should be the character of the dressings? How often should they be changed? When should the packing be dispensed with? What should be the treatment after granulation has been established? Will the deformity remain or gradually pass away? CHAPTER XLVI. CYSTOMATA (Continued). MULTILOCULAR CySTS OF THE JaWS. Definition. — A multilocular cyst is a congeries of small cysts; a polycyst; a variety of cyst having many cavities, or a cyst containing many similar smaller cysts attached to the inner wall of the original cavity. True cystoma of the bone is an exceedingly rare affection, only a very few cases ever having been reported. The most interesting one is that described by Engle, which occurred in a woman fifty-five years of age, the mother of six healthy children, and who during her life gave no evidence of any bone-affection. Death occurred from an acute disease, and at the post-mortem examination it was discovered that the entire skeleton was occupied by innumerable cysts, ranging in size from a pea to three inches in diameter. The cyst-walls were composed of a layer of connective tissue, and the cysts contained in some instances a clear, in others a bloody serum. In a few instances smgle cysts of considerable size have been found in various bones. Multiple bone-cysts resulting from "embryonic inclusion of a matrix of epithelial cells" (Senn) are most commonly associated with the maxillary bones. Tumors of this character have been observed much more frequently in the lower than in the upper maxilla. Multilocular cysts of the jaws, also known as proliferating foUicii- lar cystomata, and designated by Sutton as epithelial odontomes, are a type of cystomata that is very rare. Becker recently described two cases which were seen at the clinic at Bonn, and he has been able to find but sixteen additional cases re- ported in surgical literature. Cysts which are formed from the beginning with separate com- partments, or which are produced later by coalescence with other cysts, or bv proliferation from the original cyst, are termed multilocular cysts. Causes. — Multilocular cysts of the jaws are in most cases found associated with the teeth or with the roots of teeth which have lost their ci^owns from caries, and which have, through their septic influ- 4S0 CYSTOMATA. 48 1 ence, been the cause of long-continued irritation and inflammation. Occasionally their development has been known to follow an injury to the jaw. The etiology of this afifection has always been somewhat obscure, and even at the present time there still remains considerable doubt as to the real cause of the disease. Eve maintained that multilocular cysts of the jaws were not of dental origin, but that they were caused by an ingrowth or inclusion of the epithelial layer of the gum, and that they followed injury and long-continued irritation from diseased teeth and inflammation. He applied the term multilocular cystic epithelial tumor to these growths. Senn believes that they are developed from an embryonic inclu- sion (matrix) of epithelial cells, and that it is evident that misplaced dental germs are not the cause of the affection, from the fact that the lower jaw is most frequently the seat of the disease. This latter fact may find its explanation in the greater liability of the lower jaw, from its exposed position, to receive injuries, while the upper, from its loca- tion, is comparatively free from traumas. Sutton thinks that multilocular cysts or "epithelial odontomes arise probably from the presence of persistent portions of the epi- thelium of the enamel-organs." The origin of supernumerary teeth and small, malformed teeth or denticles often found in the dentigerous cysts may also be explained in the same manner. These persistent portions of the epithelium of the enamel-organ are derived from the epithelial cord of the tooth- germ, which has been cut off from the enamel-organ by the closing of the dental follicle. After the cord has been separated from the enamel-organ by this process, it breaks up into minute globules (Magi- tot), which are absorbed; but if for any reason they are not removed by absorption, these globules may develop into supernumerary teeth or denticles, or they may induce the formation of multilocular cysts, the "epithelial odontomes" of Sutton. Audry is of the opinion that multilocular cysts have a positive connection with the enamel-organs; he also succeeded in demon- strating the epithelial origin of these growths. Their origin, there- fore, would invest them with a certain degree of malignancy. These observations most positively confirm the first researches of Falkson and Malassez as to the origin of many of the maxillary tumors. Kruse also confirms these investigations, and considers the origin of these cysts to be the paradental epithelial debris of Malassez. Multilocular cysts are sometimes termed proliferating follicular cystoma, from the nature and character of their development, which is generally thought to be due to the gland-like arrangement of the "tumor matrix" and the proliferation of the epithelial cells. The can- 32 482 SURGERY OF THE FACE, MOUTH, AND JAWS. cellated structure of the bone may favor the multiple character and growth of this variety of cyst, by the rupture or absorption of the thin septi or partition walls which exist between the vacuoles or loculi, as the cysts grow and the fluid increases in quantit)'. The recent anatomical researches of Cryer upon the inferior max- illa also favor the supposition that the multilocular character of these cysts may be influenced by the peculiarities of the structure in which they are formed. Cryer has demonstrated the inferior dental canal to be a cribriform structure; that an abundant communication exists between the vacuoles or loculi of the cancellated tissue of the bone; that the alveoli of the teeth are not only in communication with the inferior dental canal, but with the loculi of the cancellated tissue in all directions, and with one another through the same channels, thus fur- nishing, in the opinion of the writer, a possible explanation of the multilocular character of those cysts of the lower jaw which appear ta be induced by the irritation of diseased teeth and traumatic injuries. If, therefore, this supposition is correct, a single cyst of epithelial origin, located in any portion of the alveolar process, the ramus, or body of the maxilla, might readily become multiple by the growth following the communicating canals and occupying the loculi of the cancellated tissue in its immediate neighborhood, expansion of the loculi taking place as the fluid accumulated. Inflammation alone, according to Senn, is never productive of tumor-formations, — neoplasms, — but that infiainmation occurring in the immediate neighborhood of a tumor-matrix, whether of pre-natai or post-natal origin, causes an increase or augmentation of its blood- supply, which arouses the embryonic tissue from its dormant con- dition and stimulates it to active cell-proliferation. Multilocular cysts of the jaws (Fig. 197), according to the best authorities upon this subject, may be stated to be caused by the pres- ence within the jaws of embryonic "inclusions" or "nests" of epithelial tissue — probably derived from the epithelial cords of the enamel- organs during the development of the teeth, and which have been stim- ulated to active cell-proliferation by injuries to the jaws, inducing an increase in their blood-supply through inflammatory conditions. The causes, therefore, may be divided into Predisposing or Es- sential, and Active or Exciting. The predisposing or essential cause is the presence within the jaw of an embryonic epithelial tumor-matrix. The active or exciting causes are inflammatory conditions and traumatic injuries. The disease is essentially one of early life, the majority of cases occurring under thirty years of age. Of the published cases, the youngest was an infant six months old, the cyst being congenital CYSTOMATA. 483 (IJfath), and the oldest an individual of seventy-iive years of age. The development of these cysts usually Isegins in cliildhood or at puberty, and they are of slow growth, though they may attain a very consider- able size. One case described by Falkson and Bryk reached an enormous size, the tumor weighing one and one-half kilograms, and extending from the zygomatic arch to the sternum (Senn). They are located most frecjuently in the region of the bicuspid and molar teeth. When associated with the upper jaw they may ru]5ture into the antrum of Highmore. Fig. 197. MuTiLocuLVR Cyst 01 theLowhrJaw. (After Rogers.) Pure multilocular cysts are commonly considered to be benign growths. Degenerative changes, however, are liable to occur in those cysts which are present in the middle and later periods of life, the tendency being toward sarcomatous and carcinomatous transforma- tion. Authorities, however, differ as to the original character of malignant multilocular cysts of the jaws. Some believe them to be a form of cystic degeneration of sarcomatous and carcinomatous growths, while others are of the opinion that they are malignant degenerations of multiple cysts which were originally benign. 484 SURGEKY OF THE FACE, ilOUTH, AND JAWS. The histologic character of multilocular cyst of the jaws is that of an epithehal tumor, and consists of branching and anastomosing cohimns of epithelium, portions of which form alveoli. The cells which occupy the alveoli vary ; the outer layer may be columnar, while those in the center degenerate and give rise to tissue resembling the stratum intermedium of an enamel-organ (Sutton). Clinically these cysts have a firm capsule, and are composed of a great number of smaller cysts grouped together and occupying the cancellated structure of the bone. The individual cysts vary in shape A, cuspid ; B, second mo horizontal ran iLAR Cyst ok thb Lower Jaw. (After Adams.) ; C, anterior portion of dental nerve ; D, remains of the base of the 3 excavated on its upper surface, on which lay the tumor. and size. They are usually of the dimensions of a small pea to that of an almond ; exceptionally they are much larger. These cavities are separated by thin fibrous or bony septi; when the disease is of long standing, they often communicate freely with each other. (Fig. 198.) The contents of the cysts may be a clear, limpid, mucoid fluid ; in other cases, thick and almost gelatinous, and of brown or dark-brown color. The cysts in the portions of the tumor which are growing are lined with a very red, pulpy, vascular membrane, resembling a myeloid sarcoma. CVSTOMATA. 485 Diagnosis and Symptoms. — The cystic character of these tumort may be easily ascertained by the introduction of a ti-ocar or an explor- ing needle, but the multiple character of the cyst cannot be positively demonstrated except by an incision, or by the extraction of the teeth and diseased roots involved in the cyst, which may sometimes demon- strate its character by the escape of the fluid. In making- a differential diagnosis this form of cyst must nqt be confounded with the simple cysts which follow suppurative alveolar inflammation of devitalized teeth, nor with dentigeroiis cysts, nor with cysto-adenoma, cysto-sarcoma, or cysto-carcinoma. The character of the three latter forms can only be determined by microscopic exam- ination. The symptoms are the presence of a slow-growing, painless tumor, situated in the region of the bicuspid or molar teeth,' usually in the lower jaw, but occasionally in the upper, when it may simulate mucous engorgement, or cyst of the antrum. It rarely produces ulcer- ation of the gums or infiltration or ulceration of the external tissues, but when such conditions have occurred they have always been asso- ciated with a malignant degeneration of the growth. Heath mentions three cases of this character. Prognosis.' — Multilocular cysts of the jaws are comparatively inno- cent growths ; they show very little tendency to implicate surrounding tissues, to involve the neighboring lymphatic glands, or to cause metas- tatic deposits. When thoroughly removed by surgical operation, they rarely recur. Their comparatively benign character is doubtless due to the bony capsule which surrounds them (Heath), their somewhat scanty vascular supply, and the especially marked tendency possessed by the epithelial cells lining the cysts to undergo colloid degenera- tion. The opposite is true of those cysts which are characterized by a sarcomatous or carcinomatous degeneration of their connective or epi- thelial tissues. Under such conditions there is a distinct tendency to the involvement of the neighboring lymphatics and surrounding tissues, and to the formation of metastatic tumors. Treatment. — The plan of treatment usually followed in cases of multilocular cysts of the jaws is to make the operation through the mouth, in order that unsightly scars may be avoided. It requires a higher degree of skill and a larger endowment of patience upon the part of the surgeon to operate successfully through the mouth in these cases than it does to lay open the tissues of the face and operate through an external incision. When operating through the mouth, the jaws should be separated as widely as possible with a suitable mouth-gag or prop. The mucous membrane over the cyst is then freely divided, and dissected from the 486 SURGERY OF THE FACE, MOUTH, AND JAWS. external plate of the bone. With gouge and bone-forceps the external plate of bone is cut away, exposing the character of the cyst. The bony and fibrous septi are now broken down and removed, and the inner surface of the cavity thus formed thoroughly curetted, any sharp projections of bone being' smoothed down. After irrigation, the cavity is packed with antiseptic gauze. Granulations soon spring up and fill the cavity, and gradually the expansion of the bone and the fullness of the cheek disappear, and no scar is left to mar the symmetry of the face. When the character of the cyst is of a nature that requires the exsection of a portion of the body of the jaw, the incisions should be made in such locations as will cause the least deformity by reason of the cicatrix. This may be accomplished by a vertical incision through the lower lip upon the median line, carried under the point of the chin to intercept another incision made from the angle of the jaw, following the inner border, to the median line. The soft tissues are then dis- sected from the bone and laid back upon the face. This exposes the jaw from angle to symphysis. A tooth is extracted in front of and behind the tumor. The bone is then cut through with the Hey's saw, the chain saw, or a circular saw revolved by the surgical engine, and removed. The vessels are then secured, the f?ap stitched into position, and antiseptic dressifigs applied. Bv these lines of incision the greater part of the cicatrix is hidden from view, which is a matter of considerable importance to the un- fortunate patient. Sometimes, by cutting away the diseased bone from above, it may be possible to leave a rim of healthy bone at the base of the jaw; this would be much better than to make a complete exsection, as an un- sightly deformity often results from the latter operation. REVIEW. CHAPTER XLVI. Is cystoma of the bone a conimoii or a rare affection? With what bones are the multilocular cysts most frequently associated? In which maxilla is it most often seen? What other terms are used to designate this disease? Is the disease of frequent or rare occurrence? What are the conditions which determine the application of the term iiiiil- tilocnlar cyst? What are the causes which may establish the development of this form of cyst? CVSTOMATA. 487 Is the etiology of the disease well understood? Stale the opinion of Eve as to the origin of the disease. What term did he use to designate the affection? State the opinion of Senn upon this point. What explanation is given that may account for the greater frequency of the disease in the lower jaw? State Sutton's opinion upon the origin of the disease. What process may take place in the enamel cords to form supernumerary teeth, denticles, and multilocular cysts? What other term is used to designate the multilocular cysts? What feature in their development would make such a term applicable? How may the cancellated structure of the bone favor the growth of these ■cysts? What new facts have the researches of Cryer established in relation to the inferior dental canal, the cancellated structure of the bone, etc.? Is inflammation productive of the formation of tumors? How may it cause the development of tumors? What is the stated cause of multilocular cysts of the jaws? How may the causes be divided? What is the essential or predisposing cause? What are the active causes? At what period of life is the disease most common? What is the character of the growth and size of multilocular cysts? In what region of the jaw are they most frequently located? When located in the upper jaw, what sinus may they involve? What is the nature of a pure multilocular cyst? What changes are liable to occur? Are the malignant cysts of this character benign or malignant at the be- ginning? Describe the histologic character of multilocular cysts. Describe their clinical appearance. What is the character of the contents? What is the appearance of the growing portions? How may they be diagnosed? Give the differential diagnosis. What are the symptoms? Do ulceration and infiltration of the gum and external tissues take place? What is the prognosis? How is their comparatively benign character explained? What is the prognosis for those characterized by malignant degenerations? What is the tendency in these conditions? "What is the usual location selected for the operation? WHiat is the value of operating through the mouth? Describe this operation. Describe the operation for exsection of the jaw. Describe the operation by which the conformation of the jaw may be pre- served in certain cases. CHAPTER XLVII. CYSTOMATA (Continued). Dentigerous Cysts. The term "Dentigerous Cyst" is applied by most writers to that form of cystic tumor associated with some aberration in the develop- ment of the teeth, and which prevents the normal process of their eruption. Dentigerous cysts are most often found in connection with the permanent teeth, occasionally with supernumerary teeth, but very rarely with the deciduous teeth. The disease may occur in either jaw, but most frequently in the upper. The most frequent aberrations in the development of the teeth are malpositions and malformations, and these conditions seem to be those Avhich most often act as causative factors in the production of the disease. A careful review of the literature upon the subject, sup- plemented by personal observation in an extended hospital practice, confirms the opinion that in nearly every case the aberrant tooth or teeth, including the supernumerary teeth, found in a dentigerous cyst were so malposed or malformed as to render it impossible for them to emerge from their crypts and assume a position in the dental arch. It is not to be supposed, however, that every malposed or mal- formed tooth which remains impacted in the jaws results in the forma- tion of a cystic tumor, or that even a majority of them so result. Indi- vidual teeth frequently fail to make their appearance in the dental arch, and many have been found in abnormal positions, or abnormally de- veloped, but comparatively few ever give rise to serious trouble. The disease may therefore be considered as a rare affection. Sutton applies the term "Follicular Odontomes" to the tooth- bearing or dentigerous cysts. He describes them as follows: "Follicu- lar odontomes arise commonly in connection with teeth of the perma- nent set, and especially with the molars. Sometimes these tumors attain large dimensions and produce great deformity. The tumor consists of a wall of varying thickness, which represents an expanded tooth-follicle. In some cases it is thin and crepitant; in others it may be one centimeter thick. The cavity of the cyst usually contains viscid fluid and a crown or root of an imperfectly developed tooth. Occa- CYSTOMATA. 489 sionally the tooth is loose in the folHcle, sometimes inverted, and often its root is truncated; exceptionally the tooth is absent. The walls of the cyst always contain calcific or osseous matter; the amount varies considerably. Follicular odontomes rarely suppurate." Aberrant teeth which pierce the gum are never productive of cystic tumors, though it occasionally occurs that an accumulation of serous fluid will be found surrounding the crown of an advancing tooth, but this is immediately discharged upon the tooth piercing the gum, and does not again reaccumulate. Cysts of considerable size sometimes develop in this way when the temporary teeth, particularly the molars, are retained beyond the proper time for them to be exuvi- ated. Tomes suggests that this condition may occur in teeth which are deeply imbedded in the jaws, the fluid collecting between the "enamel and the tooth-capsule, and as the fluid increases in amount the bone next to the tooth is resorbed, while new bone is formed upon the outside of the jaw." Salter says, "When a tooth is impacted in the jaw, its fang is enclosed in a bony socket, lined by periosteum, as in ordinary circum- stances, while the crown of the tooth is free in a little bony loculus lined with that which was the so-called 'enamel-pulp.' This structure is clothed with a sort of epithelium, which is apt to assume the function of secreting fluid." Causes. — All serous exudations are the result of some form of irritation, usually of a mild chronic type, but it is not always an easy matter to determine the exact character of the irritation. In cysts connected with the roots of devitalized teeth, the irritant is easily determined, but in exudations not so associated it is a more difficult matter. It would seem, however, that in the formation of dentigerous cysts the irritation was simply mechanical, identical with that which accompanies the advancing tooth in the normal process of eruption ; but on account of the malposition or the malformation of the oiifending tooth, the advancement of the crown is impeded. As a consequence of this impediment to its progress, irritation of the surrounding tissues is produced, resulting in a low inflammatory process, with serous exuda- tion, gradual accumulation of the fluids, expansion and resorption of the bone, accompanied by more or less swelling and deformity. The changes which take place in the contents of dentigerous cysts are in no way different from those which are found in connection with serous cysts in other portions of the body. The dentigerous or tooth-bearing cysts are not always confined to the jaw, but are found in the ovaries of the human female, as expres- sions of a modified form of reproduction; while those which occur in either sex, and remote from the location of the reproductive organs, must be classed as dermoid cysts. 490 SURGERY OF THE FACE, MOUTH, AND JAWS. Dermoid Cysts are formed as a result of an infolding of the epi- blast or hypoblast, which is thereby displaced and surrounded by the connective tissue. These cells thus buried in the connective tissue continue to develop, and result in the formation of an epidermal cyst (Fig. 199), which may contain any or all of those tissues which are developed from the epiblast or hypoblast, namely: the skin, hair, nails, mucous membrane, the teeth, and occasionally muscle, bone, and carti- lage; but under the latter circumstances portions of the mesoblast must have been included with the misplaced portions of the epiblast and hypoblast. Fig. iqq. Dermoid Cyst — Transverse Section. The most common location of dermoid cysts is in the generative organs, especially the ovaries. They are occasionally found in other parts of the body, like the peritoneum, the neck, the sternum (Fig. 200), the region of the orbit, the cheek near the angle of the mouth, in the median line of the chin, on the side of the nose, and in the median line of the palate. In rare cases, fragments of bone, flat or irregular, or of cartilage, and even of teeth, are found beneath the cutaneous laver. The teeth are occasionallv free within the cvst. Teeth are CYSTOMATA. 491 sometimes found in connection with the branchial clefts of sheep, oxen, and horses. Sutton mentions such a case occurring in a sheep with persistent fistula of the second branchial cleft and surmounted by a prominent cervical auricle, covered upon its posterior surface by a number of processes resembling- the buccal papillae of sheep. From this auricle grew an ill-formed incisor tooth, mounted upon a projec- tion of bone and surrounded by mucous membrane. Professor Sayer, of the Chicago Veterinary College, recently opened a dermoid cyst ^J-TBALCOMS.SC m:==^~ Dermoids ove THE Sternum and th Nineteen. KR 01- THE HyOID BoN er Sutton.) IN Bo\' AGED situated in the temporal region of a horse which had been discharging an offensive secretion for several months, and found lying upon the bottom of the cyst a well-developed incisor tooth. Dermoid cysts are classed among the congenital tumors. They are found most commonly in young persons, though they have been discovered in the aged. Their growth is usually very slow and en- tirely painless. The simple forms are those found in detached or sequestered por- tions of the surface epithelium, where during embryonic life union takes place between skin-covered surfaces; as. for instance, upon the median line of the body, and along the lines of coalescence of the vari- 492 SURGERY OF THE FACE, MOUTH, AND JAWS. ovis embryonic fissures of the face and neck. The more complicated forms are those occurring in the ovaries and in connection with mucous surfaces. Sutton is authorit)' for the statement that teeth are never found in those dermoids which arise in connection with the sur- face epithelium. They are, however, of fairly frequent occurrence in ovarian dermoids, and also in rectal and post-rectal tumors of this character. The writer is of the opinion that teeth are never found in dermoids other than those associated with the generative organs or the mucous membrane. The former class result from an abortive effort of the function of reproduction; the latter from an accident of develop- ment. The teeth are formed from the layers of the mucous membrane, the hypoblast, and not, as often stated, from the epiblast. The same accidents of displacement which occur in the epiblast may, under the same circumstances, happen to the hypoblast, which may result in the formation of tumors containing any or all of the tissues which are developed from the hypoblast, viz: the mucous membrane, with its glandular appendages, etc., and the teeth. These accidents of devel- opment explain, in a measure, the occasional presence of teeth in the cervical region of the human subject, which have been usually classed as erratic third molars. One of the most remarkable cases of dentigerous cysts ever noted is that described by F. E. Glaswald, of Pomerania, in 1844, and quoted at some length by Salter. The history of the case, as gathered from Salter, is briefly as follows: The patient was a healthy girl of about eight years of age when the disease first showed itself. The earlier symptoms were frequent attacks of violent pulsating pain in the right superior maxilla, involving the alveoli and the teeth, which were re- lieved by fomentations and general treatment. A year later the symp- toms recurred, accompanied by redness, swelling, and fever. After the subsidence of the active symptoms of inflammation, a permanent enlargement of the cheek remained, but no definite tumor. These attacks were frequently repeated during the following two years, with a constantly increasing fullness of the cheek, so that at the age of ten years the right side of the face presented a large, tumor-like promi- nence. An tmusually violent attack occurred at this time, accom- panied by inflammation of the antrum and elevation of temperature, which was supposed to have been the result of exposure to cold. At the end of five days the sinus opened spontaneously in the zygomatic region, with profuse discharge of pus. The case was then treated in hospital by Dr. Warnekros, who extracted the molar teeth, dilated the external aperture, and established a counter-opening in the canine fossa. This resulted in diminishing the size of the tumor. Five years later the left cheek was attacked in precisely the same manner, and continued until the patient was nineteen years of age. The right side CYSTOMATA. 493 also, at the same time, began slowly to enlarge. A second operation was performed at this time by Dr. Kneip by opening the left antrum, which was followed by the discharge of a large quantity of fetid pus. No necrosed bone could be discovered. The patient had now become very much disfigured, the antra remaining permanently dilated and the cheeks very prominent. A third operation was made by Professor Baum, who opened both antra and removed a portion of the external walls. Upon the left side an opening was made just below the canine fossa, which was followed by the discharge of about an ounce of clear yellow, fetid serum, and upon exploring the antrum with the finger the crown of a molar tooth was discovered firmly attached to the bone; it was extracted with difficulty. The right antrum was opened in about the same location, and a cuspid tooth was found loosely at- tached to the wall and easily removed. This sinus contained fetid pus. After several months, there was little change in the size of the tumor. Another notable case of the disease occurring in the inferior maxilla published by Mr. Fearn, of the Derby Infirmary, in the British Medical Journal, 1864, and quoted by Heath, is also of especial in- terest. The patient, a girl thirteen years of age, had a large, hard tumor, which occupied the whole of the horizontal ramus of the left side, and which had been growing for six months. The surface of the tumor showed a fetid discharge, but there was no discoverable open- ing. The right side of the maxilla was also somewhat enlarged, and the teeth irregular. The teeth of the right side had been extracted with the exception of a temporary molar and the second permanent molar. The left half of the jaw was removed from the symphysis to the articulation, under the mistaken diagnosis of a solid tumor. The tumor proved to be a bone-cyst, formed by the expansion of the two plates of the maxilla, and which extended for some distance to the right of the symphysis. The cyst was lined with a thick vascular membrane, and at the bottom a cuspid tooth was found projecting from the wall, and which was evidently the cause of the disease. (Figs. 201, 202.) Another somewhat similar case was published by Dr. Forget The patient was a woman thirty years of age, having a tumor of the right side of the inferior maxilla the size of a hen's egg, which ex- tended from the lateral incisor to the base of the coronoid process, and liad been slowly growing for ten years. M. Lisfranc removed the right half of the jaw, and upon examination of the tumor it was found to be a dentigerous cyst, with the third molar in an inverted position, the roots located in the base of the coronoid process, and the crown projecting downward and into the cyst. (Fig. 203.) The following cases from the practice of the writer are of sufficient interest in this connection to warrant their appearance in these pages: 494 SURGERY OF THE FACE, MOUTH, AND JAWS. Miss Anna T., aged sixteen years, light complexion, well nour- ished, and in general good health, was referred to the writer by Pro- fessor John Van Duyn, of Syracuse University, November 21, 1881, for a tumor of the left inferior maxilla the size of a hen's egg in the Fig. 201. Dentigerous Cyst. (After Healh.) a, unerupted cuspid tooth. Fig. 202. Dentigkrous C -Lateral View. (After Heath.) ntal foramen. reo"ion of the molar teeth, and apparently involving the entire structure of the left half of the jaw, the swelling extending upward along the ramus toward the maxillary articulation. The first molar tooth had been extracted about three months previously, under the mistaken diagnosis of an alveolar abscess. The CYSTOMATA. 495 second molar was in place, but very loose ; the third molar had not 3-et made its appearance. The swelling of the jaw, which was first noticed fifteen months before, had been of slow growth and painless, except on taking cold, when the pain was only slight and of short duration. Pressure over the tumor produced indentation of the tissues, with parchment-like crepitation, but there was no discoloration of the exter- nal integument. There was slight tenderness of the parts, and some difficulty in opening and closing the mouth, though mastication could still be performed upon the right side. With the tumor of the jaw there existed a goitre of small size. Fig. 203. Dentigerous Cvst of Lower Jaw. a, third molar inverted ; d, internal wall ; c { After Forget. ) inferior dental canal. The contents of the tumor were found to be a straw-colored serum. This, with the fact of the location of the tumor, led to the diagnosis of dentigerous cyst, dependent, in all probability, upon the unerupted third molar. The patient afterward, sought other advice, and the second molar was extracted, "followed by the escape of a thick, tenacious fluid re- sembling the albumen of an egg." The patient returned a month later for operation. In the mean time the cyst had increased to about double its former size. The tumor was laid open within the mouth, along the alveolar border, from the angle to the second bicuspid tooth, and the fluid contents of the cyst removed, which consisted of a thick, dark-yelloVv serum, slightly mixed with pus, in quantity at least four ounces. On exploration with the finger introduced into the opening, several sharp spiculse of bone could be felt upon the sides and bottom 49^ SURGERY OF THE FACE, MOUTH, AND JAWS. of the cyst cavity, — probably the remains of the alveoli of the ex- tracted teeth, — while in the posterior part of the cavity, well up toward the sigmoid notch and at the base of the condyloid process, the crown of the third molar could be distinctly outlined. This was easily dis- lodged with an elevator, and extracted by the aid of the bullet forceps. On further examination it was found that the condyloid process and the posterior part of the ramus were separated from the coronoid process and the anterior portion, and detached from the surrounding tissues, the periosteum having been entirely separated from this por- tion of the bone ; it was therefore removed through the cyst cavity and incision within the mouth. Fig. 204. Dentigkrous Cyst, with In\'frted Third Molar. The extracted condyle showed evidences of necrosis, and upon further examination it was discovered that the cyst had extended so far backward as nearly to sever the condyle from the coronoid process and body of the jaw, while the force a:pplied to dislodge the tooth, though very moderate, no doubt completed the separation. The con- dyle was also separated from its fibro-cartilage. On placing the tooth in the crypt in which it was developed on the portion of the jaw re- moved (Fig. 204), it was found to have occupied an inverted posi- tion, the grinding surface of the crown directed downward, forward, and outward. The tooth was incomplete in development, the crown only being formed. The patient made a good recovery, with reformation of lost bone and perfect mobility of the joint. Mrs. Hulda A., aged twenty-nine years, farmer's wife, came for consultation on March 8, 1882, for a tumor of the right side of the CVSTOMATA. 497 superior maxilla situated in the region of the bicuspid and first molar teeth, occupying the alveolar ridge, and about the size of a pigeon's egg, firm and unyielding to the touch. Six months previously she had the second bicuspid of the right side extracted, which was badly decayed. The first bicuspid and first molar had been lost for some years; had not noticed the enlargement of the jaw until some weeks after the second bicuspid had been ex- tracted. The formation of the tumor had been slow and painless, and she only sought advice on account of its becoming troublesome from its size and the disfigurement of the face. The tumor was punctured with a heavy exploring needle, which revealed the presence of a clear, straw-colored, thick, ropy fluid. An opening" was made through the entire length of the swelling, and the fluid discharged. The sac was then explored with the finger, and at the upper part a jagged substance was felt, which was at first thought to be a piece of denuded bone; but on removing it with the forceps. Fig. 205. First Temporary Molar (enlarged), I, pulp-chamber opened and enlarged by resorption, after considerable exertion, it was found to be a first deciduous molar of perfect form, except for the loss of a portion of the root, evidently from resorption, and placed in the jaw in an inverted position, the roots pointing downward. Resorption had been most active upon the distal aspect of the roots, and had penetrated the pulp-chamber, which was exceedingly large. The tooth was somewhat discolored, and had the appearance of having been bathed in a yellowish-brown staining fluid for a considerable period. (Fig. 205.) Mr. B., aged twent3'-four years, a medical student, consulted the writer, during the winter of 1886, for a tumor in the region of the max- illary tuberosity of the right side, behind the third molar, but which was only partially erupted. The gum-tissue was considerably swollen, and the jaw much en- larged and broadened at this point. There was a slight fullness under the malar bone, but no crepitation or fluctuation could be detected, though severe pain was at times experienced, and the tissues were painful to touch. A diagnosis of impacted or difficult eruption of the third molar being made, the tooth was cut down upon and removed, the removal being followed by a discharge of a watery fluid mixed 33 49© SURGERY OF THE FACE, MOUTH, AND JAWS. with pus, and of offensive odor. On probing the alveolus from which the tooth had just been extracted, enamel could be felt, and upon en- larging the alveolus with the bone-forceps five small supernumerary teeth were removed, of imperfect form, resembling the canines of a kitten. Several cases of this character are to be found on record. Fig. 206 shows a group of dwarfed and malformed teeth removed from a cyst by Tomes, and Fig. 207 shows three teeth removed from a cyst by Cryer. Fig. 206. Dwarfed and Malformed Teeth from a Dentigerous Cyst of the Right Side of the Upper Jaw. (After John and Charles S. Tomes.) Fig. 207. Right Upper Incisors and Cuspid found in a C^STIL Cavity. (After M. H. Cryer.) Diagnosis and Symptoms. — The question of age is one that should be considered in making the diagnosis. The disease has oc- curred as late as the sixtieth year, but the great majority of cases are under thirty years. The disease is essentially one of early life. The symptoms of a dentigerous cyst are principally local in their manifestations, and consist of expansion of the maxillary bone in some definite locality, with a corresponding deformity of the features, a sense of weight and tension, sometimes pain and general constitutional dis- turbance. Pressure over the tumor produces a peculiar parchment-like crepi- tation, and when the bone is sufficiently thinned, fluctuation may be detected. The most important diagnostic sign is the absence of one or more CYSTOMATA. 499 teeth which should have made their appearance in the nioutii, and which have not been extracted. The teeth corresponding witli the age of the patient, however, may all be in position or accounted for, and yet the fact that a supernumerary tooth may be the cause of the disease must not be overlooked. Impacted temporary teeth are very rarely met with, and the formation of a dentigerous cyst from this cause is even more rare. Fluid may be detected by the exploring needle, the trocar, or by aspiration. This should never be neglected in a doubtful case, in order that a needlessly severe operation may be avoided. The presence of a serous fluid should be additional evidence in favor of the diagnosis of a tooth-bearing cyst. The discovery of a tooth in the cyst may often be made by the introduction of a probe passed through an inci- sion made in the cyst-wall. The character of the fluid in dentigerous cysts is usually a clear, vellowish, albuminous, viscid, ropy serum; occasionally it becomes puriform when the cyst has been the seat of a suppurative inflam- mation or other changes. The subsequent changes which may take place in dentigerous cysts are the same as occur in cysts in other locations of the body, and may lead to a mistaken diagnosis. The character of their contents is subject to considerable deviation. A trauma may induce a hemor- rhage into the cavity, and the contents of the cyst be so mixed with blood as to be mistaken for an extravasation cyst; or colloid degen- eration may convert the fluid to a honey-like liquid; or calcification may occur, in floating particles of coagulated fibrin or blood-clots, while the cyst membrane may be so filled with calcareous deposits as to lead to the supposition that the tumor was an osseous growth. Heath describes a case of this character. The cyst was located in the right antrum, but had no attachment to the walls of the sinus except to its floor. Complete calcification had taken place, and upon open- ing the cyst a supernumerary tooth was found loose in the cavity, but which evidently had been attached originally to its base. Differential Diagnosis. — Cysts of the maxillary bones may be confounded with other afl^ections of this locality in which swelling or enlargement of the bone is a prominent symptom. Dentigerous cysts are commonly located in the body of the bone, and usually attain a considerable size, while cysts associated with the roots of devitalized teeth are usually confined to the alveolar process, are of much smaller size, and do not cause expansion of both plates of the bone. The fibromata, chondromata, sarcomata, myxomata, abscesses, and empyema of the antrum all cause swelling and enlargement of the parts, and consequently errors have been made in diagnosis which 500 SURGERY OF THE FACE, MOUTH, AND JAWS. have occasionally led to serious consequences. An abscess, however, can be distinguished by its rapid course and constitutional symptoms, and an empyema usually by the more symmetrical enlargement of the facial surface of the jaw. Tumors occupying the maxillary sinus some- times produce the same even enlargement, but an exploring needle passed into the tumor will usually demonstrate its character in a gen- eral way. If the contents are fluid, the needle will meet with little resistance, while the liquid will escape from the puncture made by it. On the other hand, a solid tumor will offer considerable resistance to the passage of the needle; the more dense the tumor, the greater will be the resistance. Prognosis. — A dentigerous cyst is usually a curable disease, and the deformity occasioned by the expansion of the bone is one which gradually passes away after the removal of the exciting cause. Occa- sionally, however, the deformity may persist, even after the disease has been cured. Cysts of the jaws are not themselves liable to cause serious results, but secondary complications may arise, like suppura- tion followed by septic fever, in which there would be more or less danger of a fatal termination. When properly treated, the issue of these cases is almost uni- versally satisfactor}'. They are very rarely associated with other bone-disease. Treatment. — The requirements of any treatment, to be efifective, must comprise not only the evacuation of the cyst, but the removal of the exciting cause of the disease. This may require, in some cases, an extended operation, but with skill it may be confined to the mouth. The writer cannot conceive of a condition of cyst of the jaws that may not be better and more successfully treated through the mouth than by incisions through the external tissues of the face, except where exsec- tion of the body of the jaw is required. The operation usually practiced is to open the cyst freely, and then for cosmotic reasons to cut away, with bone-forceps, gouge, or burs, the external plate of the expanded bone. Some operators prefer to crush in the external wall instead of cutting it awa}'; but in many cases this is not necessary, as sooner or later resorption will restore the normal outline of the jaw. After the fluid has been evacuated, a care- ful search must be made for the offending tooth, but such effort does not always prove successful. It is certain, however, that it is some- where in communication with the cyst, either covered by the cyst membrane or imbedded in a crj'pt and communicating with the cyst through a small opening. In large cysts with thin external wall the expanded bone may be crushed down, and afterward the cyst cavity packed with gauze and permitted to close by granulation. CYSTOiMATA. 501 In some instances there will be a persistent reaccumulation of serous fluid. Under such circumstances it may become necessary either to inject the cyst with astringent and stimulating fluids, or to i-eopen it, and, by means of a curette, thoroughly destroy the investing membrane. REVIEW. CHAPTER XLVII. To what form of tumor is the term dentigerous cyst applied? With what class of teeth are they usually associated? In which jaw do they most frequently occur? What forms of aberration in the development of the teeth most often pro- duce the disease? Are aberrations of this character hkely to cause cystic tumors? Are aberrant teeth which pierce the gums productive of cystic tumors? Under what conditions are cysts formed in connection with the temporary teeth? ■ What is the explanation of their formation? What form of irritation is productive of serous exudations? What form of irritation seems to be the prominent factor in the production of dentigerous cysts? What changes take place in the contents of these cysts? In what other locations beside the jaws are tooth-bearing cysts found? How are these classed? How are dermoid cysts developed? What is the most common location of dermoid cysts? At what period of life are they most common? What is the character of their growth, etc.? Where are the simple forms most often found? With what form of tissue are tooth-bearing cysts always associated? What is the explanation of their formation in these localities? From what embryonic tissue are the teeth formed? How is the presence of teeth in the cervical region explained? What question should be especially considered in making a diagnosis of dentigerous cysts? At what period of life are they most common? What are the symptoms? What is the most important diagnostic sign? What relation do the temporary teeth bear to the formation of dentigerous cysts? How may the fluid be detected? What would the presence of serous fluid indicate? How may the presence of a tooth sometimes be demonstrated? What is the character and appearance of the fluid found in dentigerous cysts? What are the subsequent changes that may take place in the fluid? 502 SURGERY OF THE FACE, MOUTH, AND JAWS. What conditions are to be noticed in the differential diagnosis? What other diseases may be mistaken for dentigerous cysts? How may abscess and empyema be differentiated from dentigerous cyst? How may tumors be differentiated? What is the prognosis of dentigerous cyst? Is the deformity always corrected by the cure of the cyst? What are the complications which might cause danger of a fatal termina- tion? What is the usual issue in these cases after operation? What are the requirements of any treatment that would be effectual? When should these cysts be opened? What condition would make it necessary to operate through the external tissues of the face? Describe the operation of treating a dentigerous cyst. If the offending tooth is not readily found, where is it likely to be? What should be done with the walls of the cyst? What should be the treatment when there is a reaccumulation of the serous fluid? CHAPTER XLVIII. CARCINOMATA. Definition. — Carcinoma (from the Greek za/^xtvos, a crab, and "/'•«, a tumor). (Carcinoma is a malignant neoplasm of the epiblastic group of tumors, and is formed by an active proliferation of epithelial cells from a matrix of embryonic cells, usually of congenital origin.) Carcinoma is of all diseases the one upon which the surgeon looks with the greatest dread and apprehension. It is a disease which for centuries has baffled the most earnest search for its cause, and ren- dered the highest degree of surgical skill of little benefit as a curative measure, though some little progress has been made during the last two or three decades in certain lines of investigation which have had for their object the tracing of the disease to its histogenetic origin. More recently — during the last decade — great interest has been awakened in the etiology of carcinoma, from the investigations of the bacteriologists who have endeavored to prove the bacterial origin of the disease. Up to the present time, however, the true cause of car- cinoma has not been discovered, but there would seem to be reason to hope that eventually such cause will be found, and in all probability through the researches of the bacteriologist. Investigations looking to the discovery of therapeutic measures for the constitutional treatment of carcinoma have likewise engaged the attention of many of the best minds in the profession, but so far no remedy has been fotmd which has the slightest permanent value as a curative agent. It is to be hoped, however, that with the discovery of the real cause of carcinoma will come the therapeutic remedy which will not only successfully combat its ravages, but will also furnisli the means of prevention. Origin. — Carcinoma belongs to the epithelial group of tumors. The generally accepted teaching in relation to the origin of all forms of carcinoma is the theory of Cohnheim, viz: That the disease arises from a misplaced matrix of embryonic epithelial cells of congenital origin. Senn and others believe that such tumors may also arise from a 503 504 SURGERY OF THE FACE, MOUTH, AND JAWS. proliferation of embryonic cells of post-natal origin, as the result of vari- ous forms of injury or disease which may produce a displacement of the epithelial cells into tissues where they do not normally belong, thus forming a tumor-matrix from which a carcinoma may ultimately develop. Carcinoma may be described as an atypical proliferation of epi- thelial cells (Waldeyer). (The term atypical means irregular, not con- formable to the type ; the opposite of typical.) Primary carcinomatous growths are usually found associated with tissues like the skin, mucous membrane, or glandular structures, and particularly in those glands having ducts which communicate with the external surfaces of the body, or with canals having such communications. A typical epithelial tumor is one in which the epithelial elements remain within their normal boundaries; do not break through the membrana propria and encroach upon the connective tissue. The base- ment membrane, Or membrana propria, forms the dividing line or boundary between the epithelial cells and the connective tissue. A true adenoma is an epithelial tumor of this type. An atypical epithelial tumor is one in which the new epithelial cells break through the physiologic boundaries and extend into the connective tissue. Car- cinoma is an epithelial tumor of this type. In other words, a typical epithelial tumor is formed by a proliferation of epithelial cells within epithelial tissue and in a normal location, while an atypical epithelial tumor is formed by the proliferation of epithelial cells within a tissue of a different type, and in a location where they do not properly be- long. In the consideration of primary carcinoma in unusual locations, the possibility of a post-natal origin from traumatisms or disease which may cause a displacement of embryonic epithelial cells must not be overlooked. Varieties and Structure. — Histologically, all carcinomatous tumors, of whatever form, are composed of epithelial cells, grouped and arranged in a characteristic order, in an alveolated connective- tissue stroma. The epithelial cells have their origin in a pre-existing tumor-matrix, while the stroma is derived from the connective tissue in which the essential matrix has been implanted, or into which the proliferating epithelial cells afterward migrate. The proliferation or multiplication of the epithelial cells (carcinoma-cells) of these growths is by karyokinesis (Filbry). The embryonic character of the epithelial cells is maintained throughout their entire development, which condi- tion of the cells marks the difference between the benign and the malignant types of epithelial tumors. The chief differences in structure which exist between the various forms of carcinoma — epithelioma, scirrhus, encephaloid, colloid, and CARCINOMATA. 505 glandular carcinoma — arise from their location, the type of epithelial cells of which they are composed, or the form and degree of the degen- erative changes which take place in them. Histologically, carcinoma may be divided into three forms : the squamous-celled, the cylindrical- celled, and the glandular. Epithelioma is a term which has been used to designate carcin- oma of the skin and mucous membrane, regardless of whether it orig- inated in the rete Malpighii or the glandular appendages of these tissues. Fig. Cells from an Epithelial Carcinoma of the Bladder. X 250. (After Perls.) The carcinoma-cells indicate their epithelial origin by their pe- culiar form. (Fig. 208.) These cells are large, of varying sizes and shapes, containing one or more round or oval nuclei with large, glistening nucleoli (Warren). The stroma is composed of fibrous tissue, more or less infiltrated with small, round cells, and traversed by blood-vessels. The stroma may be abundant or scanty. In the slow-growing, hard forms of car- cinoma the stroma is abundant, while in the rapid-growing, soft va- riety it is scanty. The blood-vessels and lymphatics are located in the stroma, 5o6 SURGERY OF THE FACE, MOUTH, AND JAWS. through which they ramify in ah directions. The blood-vessels, unlike those in sarcoma, are normal in thickness and construction, and are confined in their ramifications to the stroma, while in sarcoma they pass among the cells. The blood-supply is always increased in the devel- opment of carcinoma. The general plan of the histologic structure of all forms of carcinoma is the same, but each variety has some pe- culiar characteristic in the form and arrangement of its cells which distinguishes it from the others. These may be briefly described as follows : Fig. 209. A Cell-Nest ff a, stroma of the alveolus phery; c, prickle-cells ; rf, compressed squamou [ A Cancer of the Lip, ■' 300. (AfterJ.D. Hamilton.) which the cell-nest is contained; ^, small germinal cells of the peri- , degenerated cells in the center. Squamous-Celled Carcinoma. — This variety is located in the skin, the squamous epithelial cells of which are arranged in concentric layers within the alveoli, forming what are known as "cell-nests," "can- cer-nests," or "epithelial pearls." The oldest cells are found in the center of the nest, the young cells at the periphery. (Fig. 209.) Car- cinoma grows or extends by the migration of the cancer-cells — which possess an amoeboid movement — into the connective-tissue spaces. Each cell possesses the power of multiplication, and thus new colonies are formed. With the growth of the colony there is a separation of the connective-tissue fibers, resulting in the formation of an alveolus. This process goes on indefinitely, with greater or less rapidity, accord- ing to the resistive power of the tissues. This form of the disease is usually described under the term "epithelioma." ■ CARCINOMATA. 507 Cylindrical-Celled Carcinoma. — This form of the disease is found in the mucous membrane, the columnar or cyHndrical cells of which are arranged in the form of tubules, simulating the structure of tubular vJr^^j2i^7/>>:xf£-/'5.i^l/''' Carcinoma of the Rectum — a Single Tuia 1 1 Mlltiplication of Cells in its Lining. ,170. (Aiteibenn.) (7, space due to shrinkage in hardening. Epithelioma — Cylindrical— of Stomach, x 200. glands. This tubular structure corresponds to the cell-nests of the squamous-celled variety of the disease. The arrangement of the col- umnar cells does not follow the typical form of a tubular gland, but ^o8 SURGERY OF THE FACE, MOUTH, AND JAWS. forms an irregular lining of the crypts. In this respect it differs from' adenoma, in which the typical form of the tubules is present. (Figs. 210, 211.) Infiltration of the stroma with leucocytes and young carcinoma- cells is a common condition. This indicates its tendency to rapid growth and malignancy. Mucoid and colloid degeneration of the cylindrical cells and stroma frequently attends this form of carcinoma. Fig. 212. erate growtl and medul lary in char acter. Carcinoma— SciRRHUS—i Glandular Carcinoma.- — The location of this form of carcinoma is in the conglomerate glands, like the mammas, kidneys, liver, tes- ticles, etc., the acini of which present the same alveolated structure of the stroma as is found in the squamous-celled variety. In glandular carcinoma the acini of the gland constitute the alveoli, while the con- nective tissue between them forms the stroma. The size of the alveoli and the amount of the stroma are governed by the character of the growth and the degree of malignancy. In the hard, slow-growing varieties the alveoli are small and the CARCINOMATA. 5O9 Stroma abundant, while in the rapid-growing, soft varieties .the stroma is scanty and the alveoh large. It may therefore be stated as a well- established fact that in proportion as the alveoli are large and the amount of connective tissue which makes up the stroma or reticulum is small, so will be the degree of malignancy of the disease. The term scirrlms cancer has been applied to the hard, slow- growing variety of carcinoma. This form of the disease is found most frequently in the mammary glands; it is also occasionally found in the stomach, testis, ovary, pancreas, and kidney. (Fig. 212.) To the soft, rapidly-growing variety the term cncephaloid cancer has been applied, from its resemblance to brain-tissue. It is most fre- quently found in the mucous membrane, the liver, testis, bladder, kidney, ovary, fundus oculi, and occasionally in the breast. The epithelial cells in both these varieties are spheroidal. This is due to the fact that the epithelium in which the neoplasm originates is spheroidal rather than columnar. Retrograde changes in cancerous growths frequently take place in the cells and stroma at a very early period in their history. Fatty, mucoid, and colloid degenerations are prone to occur in the cells of glandular carcinoma. Calcification is occasionally seen in cancers of feeble growth. To these degenerative changes is due the confusion which has arisen in the classification of carcinomatous growths. A very rare and peculiar form of carcinoma is a variety known as Cylindroma carcinoviatodcs. This variety of the disease is a species of colloid degeneration occurring primarily in glandular structures. Ziegler states that he had observed but one case, and this was asso- ciated with the lachrymal gland. Histologically it is "characterized by the formation of homogeneous spherules within the cell-nests. These spherules are generally regarded as masses of colloid substance which press asunder the other cells of the group. If a considerable number of these spherules form within the same loculus, the cells may be compressed into slender trabeculse, and so come to form a kind of anastomosing net-work." (Ziegler.) Fig. 213 shows a primary growth of this character which was located in the stomach, most of which was in a state of colloid degeneration, and Figs. 214 and 215 metastatic growths in the liver and the brain from the same case. Infection and Dissemination. — All true carcinomatous growths are clinically of a highly malignant character. Progressive infection of the immediately surrounding tissue, of the neighboring anatomic structures, and general dissemination of the cancer-cells through the lymphatic and circulatory apparatuses mark? the malignant character of carcinoma. These conditions are made manifest in the progressive growth of the tumor, in tlie involvement of 5IO SURGERY OF THE FACE, MOUTH, AND JAWS. Fig. 213. Cylindroma Carcino.matodes. Primary Growth of the Stomach. X 75. .(A.) a, stroma with round-celled infiltration ; b, carcinoma cells ; c, alveoli or acini. Fig. 214. Cylindroma CARC]N0ivL-\TODES. Metastatic of the Liver, from a Prla^ary Growth in the Stomach. X 75. (B.) fl, tatty degeneration of liver-cells ; b, carcinoma. CARCINOMATA. 511 ihc neighboring healthy tissues, regardless of the character of these structures, and in the formation of secondary carcinoma in distant organs and tissues which have no anatomic relationship to the tissues which are the seat of the primary disease. The local extension of carcinoma to all tissues and organs, irre- spective of their structure, is the most marked feature in the pathology and the clinical history of the disease, and may be considered almost a pathognomonic sign. The use of the term infection, as applied to tumors of malignant type, rests upon the power possessed by the "cancer-cells" to leave the Fig. 215. Cylindroma Carcinomatodes, ROM A Primary Growth in the rt, degeiierat primary tumor and to wander into the surrounding healthy tissue, thus establishing new centers of growth; or by being transplanted through the lymphatic channels or by the blood-current, to reproduce the dis- ease in contiguous regions or in distant parts of the body (Senn). This power to migrate and multiply in the mesoblastic tissues which is possessed by the cancer-cells does not explain the malignancy of such growths. Waldeyer and Thiersch both observed and described the power of epithelial cells to penetrate into tissues of apparently healthy char- acter, but "normal epithelial cells do not possess the same power of 512 SURGERY OF THE FACE, MOUTH, AND JAWS. multiplication in the mesoblastic tissues as do the epithelial cells of carcinoma" (Senn). It may therefore be stated with some degree of certainty that some change, at present not understood, takes place in the epithelial cells, which increases to a marked degree their power of multiplication, while at the same time the resistive powers of the tissues in which they are implanted are more or less lowered. These changes may be due to the influence of a specific micro-organism which has gained access to the tissues, but proof upon this point has not been demonstrated. If this is a correct view of the conditions, it may be readily understood how the growth and progress of carcinoma on the one hand may be rapid, while upon the other it is slow, these conditions depending upon the rapidity of cell-proliferation and the physiologic resistance of the tissues in which the disease is found. Malignancy, however, depends not only upon the progressive growth of the neoplasm, but upon the infection of other tissues in its neighborhood and its general dissemination throughout the body, causing numerous other centers of cancerous growth. Local infection takes place by the migration of young carcinoma- tous cells from the periphery of the tumor into the connective-tissue spaces. The progressive extension of the growth is always in the direction of the pre-existing connective-tissue spaces, consequently it spreads most rapidly and attains its largest dimensions when located in regions supplying an abundance of loose connective tissue. Regional infection is the result of the transplantation of patho- genic material from the seat of the primary tumor to the lymphatic glands of the region, through the lymph-channels. It is a well-estab- lished clinical fact that the lymphatics in the immediate neighborhood of a primary carcinoma sooner or later become affected, and that the secondary' growth is in all respects similar to the primary tumor. The pathogenic material carried to the 13'mphatic glands is generally be- lieved to be young carcinoma-cells which have found their way into the lymph-channels and have been carried by the lymph stream and deposited in the glands. The glands, acting as filters, arrest the fur- ther progress of the cancer-cells, and new foci are established for the development of the disease in these structures. (Fig. 216.) Paget was of the opinion that even minute portions of the proto- plasm of the carcinoma-cells were as effective in reproducing the dis- ease as the whole cells. Gussenbauer believed secondary carcinoma to be due to the transplantation of minute infective corpuscular elements from the primary tumor to the lymphatic glands through the lymph channels. General infection is expressed in the development of carcinoma- tous tumors in tissues and organs in distant locations of the body which have no anatomic relationship with that portion of the body in CARCINOMATA. 513 which the primary tumor is located. The dissemination of the in- fective material is brought about through its entrance into the general circulation. This may be accomplished either by direct entrance to the blood-current through the perforation or injury of a vein-wall, or by indirect entrance through the lymphatic system. Such material is capable of passing through the pulmonary circulation, and of being carried to remote portions of the body, where it ma}' become arrested in the capillaries, forming an embolus from which a carcinomatous growth ma}' develop. This process of dissemination is termed meta- stasis, and the tumors developed from such process metastatic tumors. Fig. 216. Secondary Carcinom\ or Limph^til Olani: ■a, a, groups of carcinoma-cells ; d, lymphoid corpuscles nests is the product of tissue-proliferati< of a single ( iiie-third. (.WterSenn.) Each on e of the epithelial rciiioma c ell. The size of the carcinomatous emboli will in large measure deter- mine the location of the metastatic tumor (Senn). Large emboli may become lodged in the pulmonary artery, while the minute ones pass the pulmonary capillaries and enter the arterial circulation, where they may become attached to the walls of the vessels or pass on until they form emboli in vessels too small to admit them to pass. In this way only the presence of metastatic carcinoma in locations which have no anatomic connections with the seat of the primary disease can be ex- plained. The organs which are most frequently the seat of metastatic car- cinoma are the lungs and the liver. The bone is occasionally the seat of secondary carcinoma, and Wagner has collected fifteen cases of this form of the affection in the choroid. Metastatic carcinoma of the lungs sometimes becomes a supply station from which the entire body mav become infected with "miliarv carcinosis." This form of the dis- 5H SURGERY OF THE FACE, MOUTH, AND JAWS. ease closely resembles miliary tuberculosis in its appearance, and is a rapidly fatal form of the disease. Figs. 217, 218, 219, 220, 221, show Fig. 217. Mammary Gland of Cat (A). Carcinoma — Scirrhus — Primary growth. Metastatic nodules appeared in tlie kidneys, intestine ungs, heart, and spleen. Fig. 218. m^M\ Kidneys of Cat (B). , metastatic carcinoma nodules. primary scirrhous carcinoma of the mammary gland of a cat and meta- static infection ("miliary carcinosis") of the lungs, the spleen, the kid- neys, heart, stomach, ovaries, uterus, and the intestines. CARCINOMATA. 515 Prevalence. — Climate and habit of life, sex and age, all seem to €xei"t a more or less marked influence over the prevalence of cancerous disease. Carcinoma is said to be less prevalent in the torrid than in the temperate zones, and most frequent in damp, low-lying districts. Negroes are thought to be less liable to the disease than the white race. The aboriginal races are singularly exempt from the disease. Few cases have been reported among the North American Indians. Ftg. 219. Stomach and Intestines of Cat (C). Metastatic carcinoma nodules. The disease seems to be peculiarly an affection of the higher civiliza- tion, and influenced to a considerable degree by climatic conditions. Some idea of the prevalence of the disease may be gained from the statement that there are about thirty thousand persons at all times in England suffering from cancer. The census of 1880 of the United States gives the deaths during that year from cancer as 13,068, of which 4875 were males and 8193 were females. Billings states that cancer is especially prevalent in the New Eng- land States and on the Southern Pacific coast; that it is prevalent in New York, Pennsylvania, Ohio, and in the interior of Michigan and 5i6 SURGERY OF THE FACE, MOUTH, AND JAWS. the southern part of Wisconsin. It is least prevalent in the Mississippi Valley and in the South, while the proportions are generally lower in the coast regions than in the interior. Park claims that the cancer mortality is greater in Western New York and the adjoining region than in any other part of the country except a limited section of California. Sex. — Carcinoma in general is much more common in women than in men, and sex seems to exert a strong influence in determining the location of the disease. Carcinoma of the lip and of the pyloric Fig. 221. Heart and Lungs of Cat (D). Metastatic carcinoma nodules. Spleen of Cat (E). Metastatic carcinoma nodules. orifice of the stomach are common in men, but rare in women, while, on the other hand, carcinoma of the breast and of the genitals are frequently seen in women and very seldom in men. Age.- — Carcinomatous growths are most prevalent in persons who have reached or passed middle life. They are extremely rare in early life and very common in advanced age. Senile tissue changes seem to be particularly favorable to the development of the disease, while the consequent lowering of the powers of vital resistance and recuperation incident to advanced age places the tissues in a condition most favor- able for the rapid growth of a tumor-matrix and the dissemination of the carcinoma-cells throug-h the svstem. CARCINOMATA. 517 Paget has published an interesting table showing the influence of age and tlie general increasing mortality of cancer with each suc- ceeding decade from birth to eighty years of age: facet's table. Under 10 years S per cent. Between 10 and 20 years 6.9 " 20 " 30 " 21 " 30 " 40 " 48.5 " " 40 '' SO " 100 " 50 " 60 " 113 " 60 " 70 . " 107 70 " 80 " 126 " Walshe has also shown from statistics that the death rate from cancer "steadily increases with each decade until the eightieth year." When the disease occurs in young persons it is an evidence that the epithelial cells composing the tumor-matrix are unusually en- dowed with the power of cell-proliferation, or that the individual is peculiarly susceptible to cancer formation: or that the tissues contain- ing the misplaced epithelial cells have sustained an injury of some form which has lowered their vitality or physiologic resistance, and placed them in a condition to favor the growth and multiplication of carcinomatous cells. REVIEW. CHAPTER XLVIII. Give the definition of carcinoma. Has the cause of carcinoma been discovered? At the present time what line of investigation seems to give the greatest hope of finally discovering the cause? What results have been obtained in searching for a curative agent for the disease? What is the generally accepted teaching as to the origin of the disease? How has this theory been modified? How may carcinoma be described? Give the meaning of the term atypical. With what tissues is primary carcinoma usually associated? Describe the typical epithelial tumor. Describe an atypical epithelial tumor. What possibility should not be overlooked in considering primary carcin- oma in unusual locations? What are the histologic elements of carcinomatous tumors? From what are the epithelial cells derived? 5l8 SURGERY OF THE FACE, MOUTH, AND JAWS. From what is the stroma derived? How do the "cancer-cells" multiply? What does the persistent characteristic of the epithelial cells make manifest? What gives rise to the differences in structure of the various forms of car- cinoma? How may the carcinomata be divided histologically? To what fonns has the term epithelioma been applied? By what peculiarity do the carcinoma cells indicate their epithelial origin? What are the characteristics of the cells of this variety? What are the characteristics of the stroma? In what forms of carcinoma is the stroma abundant? In what form of carcinoma is it scanty? Where are the blood-vessels and lymphatics located? How does this condition differ from sarcoma? How is the blood-supply affected in the development of carcinoma? Is there any difference in the general plan of the histologic structure of the forms of carcinoma? How are the varieties distinguished? What is the location of the squamous-celled carcinoma? Describe its histologic structure. How does carcinoma extend its boundaries? How are the alveoli formed? What is this form of carcinoma usually termed? Where is the cylindrical-celled carcinoma usually located? Describe the structure of this form of the disease. How does this form differ from adenoma? What other term is applied to this form of carcinoma? What is a common condition of the stroma? What does this indicate? What forms of degeneration are common in this form of carcinoma? Where is the glandular carcinoma usually found? Describe its histologic structure. What governs the size of the alveoli and the amount of the stroma? In what variety of glandular carcinoma are the alveoli small and the stroma abundant? In what variety are the alveoli large and the stroma scanty? What term has been applied to this slow-growing form of carcinoma? In what organs is this variety of the disease usually found? What term has been applied to the soft, rapid-growing glandular car- cinoma? In what organs is this variety most frequently seen? What is the form of the cells in both of these varieties? When do the retrograde changes frequently take place? What form of degeneration is prone to take place in glandular carcinoma? What has been the effect of these degenerative changes upon the classifica- tion of tumors? What is the clinical character of all true carcinomatous growths? What marks the malignant character? How are these conditions made manifest? Which is the most marked feature in the clinical history? May this be considered as pathognomonic? What is understood by the term infection as applied to malignant growths? Does this power explain the malignancy of such growths? CARCINOMATA. 519 What indications are tlionglit to be responsible ior the malignant character of tiiese tumors? What other conditions are marks of malignancy? How does local infection take place? In what directions does it spread? How does regional infection take place? What is the character of the secondary growths found in the lymphatics? What is the form of pathogenic material carried by the lymphatics? How do the lymphatic glands arrest the progress of these cells? What is Paget's view as to the material which would reproduce the disease?' What is the opinion of Gussenbauer upon this subject? How is general infection expressed? How is this condition brought about? Through what channels does it enter the circulation? How does it reach the capillaries of distant parts of the body? What is this process of dissemination termed? What are the tumors called which are formed by this process? What in large measure determines the location of the metastatic tumor? What organs are most frequently the seat of metastatic tumors? From what form of metastatic tumor may general miliary carcinosis take place? What disease does miliary carcinosis resemble? What are the conditions which influence the prevalence of carcinoma? In what climate is it most prevalent? How are the negroes and whites affected by the disease? How does it affect the aboriginal races? In what form of civilization is it most prevalent? How many persons are said to be affected at all times in England? How many deaths occurred in the United States from the disease in 1880? In what sections of the United States was it most prevalent? Where was it least prevalent? What is Park's opinion upon the sections in which it is most prevalent? In which sex is carcinoma most common? Does sex seem to influence the location of the disease? In what locations of the body is the disease common in men and rare in women? In what locations is the disease most common in women? In what individuals is carcinoma most prevalent? At what period is it most rare, and most common? What conditions of the system are most favorable to its rapid growth and dissemination? How does age affect the mortality from the disease? What is the explanation of the appearance of the disease in young persons? CHAPTER XLIX. CARCINOMATA (Continued). Causes.- — Until some better theory is advanced to account for the origin of carcinomatous growths, we must hold fast to the modified theory of Cohnheim, that all such neoplasms arise from the presence in the mesoblastic tissues of a matrix of embr3'onic epithelial cells of pre- natal or post-natal origin. The essential factor in the production of all forms of epithelial neoplasms, benign and malignant, is the presence of misplaced epithelial cells in tissues of mesoblastic origin, but the influ- ences or agencies which impart innocency or malignancy to growths which in their incipiency are histologically identical, — for all carcin- omas have a benign stage, — have not yet been revealed. The etiology of the disease, therefore, presupposes the existence of an essential cause with a predisposition or tendency to the develop- ment of carcinomatous growths ; and active or exciting agencies which stimulate the essential cause into active cell-proliferation. The essen- tial cause, if not excited to activity, may remain in a dormant condition for years, or never give evidence of its presence within the tissues. The essential cause of all carcinomatous growths is the presence within the mesoblastic tissues of embryonic epithelial cells of congenital or post-natal origin. "In the absence of such an essential histologic basis, no exciting cause or combination of exciting causes will result in the production of a carcinoma." (Senn.) The congenital origin of the tumor-matrix is by far the most fre- quent. The tumors which arise from post-natal influences, if the inves- tigations of Cohnheim, Billroth, and others, upon the cause of carci- noma, are correct, amounts to about 20 per cent. Boll's statistics place it at 14 per cent. Wolff's yielded only 12 per cent. The post- natal influences which give origin to the formation of carcinoma are traumatisms which bury fragments of embryonic epithelial tissues in structures of mesoblastic origin; or portions of these tissues which are buried in the process of healing of wounds, or the repair of lesions of inflammatory origin. Such a tumor-matrix acts as a foreign sub- stance, inducing vascular excitement in its immediate neighborhood with the proliferation of embryonic epithelial cells, which, failing to- reach maturity, become carcinomatous tissue. 520 CARCINOMATA. 52 1 Cohnheim, Leopold, and Zahn found by experiments that mature tissue, transplanted into the anterior chamber of the eye and the peri- toneal cavity of rabbits, was invariably removed by absorption in a very short time; while, on the other hand, embryonic tissue which had been taken from animals before they were born, and transplanted into living animals, not only retained its vitality, but continued to grow to an ex- tent which was very remarkable. Fetal cartilage grafted in this man- ner increased in bulk from two to three hundred times its original size. The most prominent predisposing cause of carcinomatous growths is diminished vital or physiologic resistance (Thiersch), either of the entire organism or of the particular location surrounding the tumor- matrix. The agencies which produce these conditions have not been demonstrated, though there is good reason to believe that many times the predisposition is an inherited one; while in others it is the result of traumatisms and of local pathologic lesions. Heredity. — It is generally believed that certain individuals inherit a predisposition or tendency to the development of carcinomatous tumors; and that the disease may seemingly be transmitted in an un- broken chain for several generations, or may show itself only occasion- ally, skipping one or two generations to reappear in a succeeding one. There is no more reason to doubt the possibility of the hereditary transmission of a peculiar condition of the tissues which predisposes them to the formation of carcinomatous tumors than there is to doubt the possibility of certain congenital deformities, peculiarities of physi- ognomy, or mental proclivities being directly transmitted from parent to child, or suppressed for a time to reappear again several genera- tions later, or in a distant branch of the family, for proofs of their occurrence are plentiful. Broca has placed on record the most interesting instance of inher- ited predisposition to carcinoma that can be found in medical literature. Madame Z. died of cancer of the breast, in 1788, at the age of sixty. Of four married daughters, — A died of cancer of the liver in 1820, at the age of sixty-two; B in 1805, at the age of forty-three; C of cancer of the breast in 1814, at the age of fifty-one; D in 1827, at the age of fifty-four. Of five daughters and two sons born to Madame B, first son died in infancy; second son died of cancer of the stomach, at the age of sixty-four; first daughter died of cancer of the breast, at the age of thirty-five; second, third, and fourth daughters died of cancer of the breast, at the ages of thirty-five to forty. The fifth daughter escaped the affection. Madame C. gave birth to five daughters and two sons. Both sons remained free from the disease. The first daughter died of can- cer of the breast in 1837, at the age of thirty-seven. This woman had 522 SURGERY OF THE FACE, JIOUTH, AND JAWS. five children, — one, a daughter, died in 1854, of cancer of the breast, at the age of forty-nine; the second daughter died of cancer of the breast in 1822, aged forty; the third daughter died of cancer of the uterus in 1837, aged forty-seven; the fourth daughter died of cancer of the breast in 1848, aged fifty-five; the fifth daughter died of cancer of the hver in 1856, aged sixty-one. Paget has found carcinoma of the uterus in three successive gen- erations, — grandmother, mother, and daughter. Sibley has seen it in two generations. Warren has related an instance of cancer of the lip in the father and one son, and cancer of the breast in two daughters. Senn has observed cancer of the breast in two successive genera- tions. Such family tendencies, however, though proving a hereditary predisposition in certain individuals to the development of cancerous growths, have not been observed in sufficient numbers to establish the law of hereditary transmission of the disease. Lebert, out of 102 cases, could find but ten who had ancestors that had suffered from the disease. Leroy d'Etoilles found but one out of 278 cases giving such a history. Gross analyzed 1164 cases, and found but 4.72 per cent, which could give a history of this character. Statistics therefore prove that hereditary transmission of the dis- ease is rare. Bacteria. — During the past few years considerable interest has been awakened in the question of the microbic origin of carcinomatous growths. The disease presents many features in its clinical histor}' which point to an infective origin, but the proofs necessary to estab- lish the fact have not been, up to this date, presented. It would not be wise, however, to say that such proofs can never be furnished, for the writer remembers that such statements were made in reference to tuberculosis, a disease which was thought by many to be infectious in character long before the bacteriologist demonstrated the Bacilhis tuberculosis and its infectious nature. The difficulties which stood in the way of demonstrating the presence of the tubercle bacillus were largely those of discovering suitable staining reagents. Difficulties now confront the bacteriologist in his efforts to demonstrate a cancer bacillus, but they are no greater than those overcome in relation to tuberculosis. It is possible, therefore, that a micro-organism may yet be discovered in carcinoma, which will fulfill all the requirements of Koch's law. The discovery of such a micro-organism would work a complete revolution in the generally-accepted teaching of the origin of carcino- matous tumors. Exciting Causes. — The presence of a tumor-matrix of epithelial cells in mesoblastic tissues is not always productive of the develop- CARCINOMATA. 523 nient of a carcinomatous tumor. Such a matrix may remain dormant to the end of hfe, unless stimulated to activity by some agency outside •of itself. Traumatisms, inflammatory lesions, particularly the chronic forms, continued local irritation, and senile tissue-changes are potent factors in exciting an existing tumor-matrix to active cell-proliferation. This may be explained by the fact that tissues which have suffered damage of any sort have not the same resistive power against disease that was possessed by the same tissues in a normal state ; while the increased quantity of blood supplied to the part suffering from injury stimulates the misplaced epithelial tissue to active cell-proliferation. According to Paget, about one-fifth of those who are the victims of ■carcinoma ascribe the disease to some form of injury. In some cases, the disease follows immediately after the injury; in others it shows itself at a more remote period; while in another and larger class, repeated injuries are necessary to produce such a result. Senn believes that "no amount or kind of injury will produce a carcinoma without the pres- ence of the essential tumor-matrix." The senile tissue-changes cause the development of such neo- plasms by diminishing the physiologic resistance of the tissues. These changes are different from those which take place as a result of debili- tation from disease or insufficient nourishment, as is evidenced by the fact that individuals suffering from marasmus caused by debilitating disease or starA^ation are no more liable to be affected by carcinoma than persons of the same age who are in other respects in perfect health. (Senn.) Thiersch has observed that in the lips of old persons the fibrous tissue wastes away, while the glandular structures increase in size, thus predisposing to the development of carcinomatous tissue. Inflammatory lesions of chronic type are not infrequently the ex- citing cause of carcinoma, and both acute and chronic inflammation, as well as wounds in the process of healing, may become the starting- points of carcinoma by the inclusion of embryonic epithelial cells within the granulation or cicatricial tissue, thus furnishing not only the exciting cause of the disease, but the post-natal essential cause as well. Insignificant injuries, like punctures, abrasions, and slight wounds, have occasionally been the only recognized exciting cause of the disease. Irritation of a continued and prolonged character is the most com- mon exciting cause of carcinoma, as is evidenced by the fact that carci- noma is frequently seen in those localities which are subjected to re- peated and prolonged irritation. These localities are situated at the entrances of the body, viz : the lips, the nose, the rectum, the labia, and the cervix uteri. 524 SURGERY OF THE FACE, MOUTH, AND JAWS. Prolonged irritation of the tongue or cheeks from the sharp edges- of carious teeth, or from accumulations of salivary calculus, are often exciting causes of cancerous growths. Warts and moles which have been the subjects of irritation or in- flammation, may also become the starting-points of carcinoma of the skin. Tubercular lesions of the skin have been thought to be productive of carcinoma from the inflammatory irritation, and also to furnish the essential cause by the inclusion of epithelial elements in the process of healing. Diagnosis and Symptoms. — The correct and early diagnosis of carcinoma is a matter of the greatest importance to the afflicted indi- vidual, for upon it rests the grave question of life or death. The diag- nosis of this disease is sometimes an exceedingly difficult task, and the very best diagnosticians do not always succeed. The difficulties which surround the diagnosis of the disease de- pend upon the stage of development and the location of the tumor. In carcinoma of the external parts, when the disease is in an advanced stage of development, the diagnosis presents no difficulties; but when located in some internal organ diagnosis becomes many times an im- possibility, and the true nature of the disease is not discovered until after death. The life of the patient depends upon an early and positive diagnosis, and prompt radical measures in the surgical treatment. To reach an early diagnosis requires a careful consideration of the clinical history, of the family history, of the signs and symptoms pre- sented, and a painstaking examination of the tumor itself. The micro- scope only will reveal the epithelial character of the tumor, and such examination should always be made when possible. The presence of embryonic proliferating epithelial cells in mesoblastic tissues is the most reliable evidence of the carcinomatous nature of the tumor. When doubt exists as to the true nature of a suspicious tumor, in- oculation experiments may be necessary to differentiate between car- cinoma and an infective swelling. In the diagnosis of doubtful tumors the age of the patient becomes an important and interesting element, for statistics show that the disease is most prevalent in persons of mid- dle or past middle life, the ratio increasing with the age. All unex- plainable tumors, therefore, occurring in individuals past middle life, should be diagnosed as suspicious growths, and treated accordingly. The location of a carcinoma is largely influenced by the sex of the patient. Carcinoma of the pyloric orifice of the stomach and of the lip are most common in men, while cancer of the breasts and of the geni- tals are most common in women. Another important element in the diagnosis is the rapidity of the growth of the tumor. As compared with the benign tumors', carci- CARCINOMATA. 525 noma grows much more rapidly, and on this account might be mis- taken for an inflammatory swelhng. In differentiating between a carcinoma and an inflammator}- swelhng, it should be remembered that, as a rule, an inflammatory swelling increases in size much more rapidly than a carcinomatous growth. The inflammatory swellings for which carcinomas may be mistaken are tuberculosis, gumma, chronic suppuration, and actinomycosis. Infection of neighboring lymphatic glands is an important symp- tom, and one of common occurrence in carcinoma; but this is not a pathognomonic sign, as it may occur in connection with certain infec- tive swellings and tumors, of different structure having malignant ten- dencies. Dilation of the superficial veins is usually present, due to in- creased vascularity or to obstruction in deep-seated veins, but this con- •dition is quite as common in infective swellings as in carcinoma. Edema is also present in carcinoma in those cases where regional infection has caused obstruction of the lymphatic or venous circulation, •or when the neoplasm has become infected with pus-producing bac- teria. Tendei^ness and pain are not characteristic symptoms of carci- noma, as is generally supposed by the laity. These symptoms are much more prominent, as a rule, in infective swellings than in carci- noma, although in the advanced stages of the disease they may become more or less marked. Carcinoma of the pyloric orifice of the stomach is comparatively a painless disease, the suffering accompanying it being due more to the obstruction of the orifice from the growth of the tumor than from the tumor itself. Carcinoma of the rectum is productive of little pain except during the passage of feces, and for this reason it -often occurs that the patient has been affected with carcinoma for some time before seeking advice, thinking all the time that the case was one of hemorrhoids. Carcinoma of the lips, cheek, and tongue is not usu- ally attended with much pain. The sharp, lancinating pain commonly- described as characteristic of carcinoma is by no means constantly present, but is frequently intermittent in t3'pe. Tenderness is usually absent in carcinoma, except in its later stages. Redness also is rarely present except when the skin is involved and about to break down with ulceration. One of the most characteristic diagnostic symptoms of carcinoma is the fixation of the tumor. Benign tumors are usually encapsulated, consequently are not, as a rule, fixed to surrounding tissues by adhes- ions, but are freely movable in all directions. In carcinoma the oppo- site conditions obtain, for this is an infiltrating tumor, causing immo- l)ility, and having well-defined margins and a nodulated surface. Ulcerating- tumors present the greatest difficulties in the diagnosis 526 SURGERY OF THE FACE, MOUTH, AND JAWS. of carcinoma. Syphilis, tuberculosis (lupus), and chronic ulcers of the leg are most frequently mistaken for carcinoma. In cancer of the breast, as soon as the skin breaks, the ulcer shows a marked tendency to spread, and presents the typical appearance of a cancerous ulcer, viz : raised and rampart-like edges, surrounding an ir- regular depression, the floor of which is covered with firm granulations,, and discharges a foul, ichorous, or blood-stained fluid. (Sutton.) On section of a carcinoma a juice exudes from the cut surfaces,, which is very characteristic of the disease. The constitutional effect produced by carcinoma is known as the cancerous cachexia, and consists in rapid emaciation, anemia, and loss of strength (Warren), but the means by which these conditions are brought about are not understood. Prognosis.' — The prognosis of carcinoma will depend very largely upon its location, its histologic character, and the stage of its devel- opment when presenting for treatment. Carcinoma of the skin is usually the squamous-celled variety. This is much more chronic in its course than either the cylindrical or the glandular-celled variety, and, being located usually upon an ex- posed surface of the body, attention is called to its existence, and relief is sought at a much earlier period than when the disease is located in an internal organ, or in the mucous membrane in locations which cannot be inspected by the patient. Under the latter circumstances the dis- ease is often so far advanced before surgical advice is sought, that radi- cal treatment would give no hope of eradicating the disease. A favorable prognosis could only be given in such cases as had not infected the nearest lymphatic glands, nor infiltrated the surround- ing tissues to any considerable degree, and in such a location as to permit of its complete removal by a radical operation. When infiltra- tion is extensive, or a chain of glands has been infected, there is always considerable doubt existing as to whether all infected tissue has been removed. In a large majority of cases the inference is that it has not been, as recurrence after a few months is the usual outcome of opera- tions performed at this late period. If the disease has reached the stage of the formation of a metas- tatic tumor, or of miliary carcinosis, there is no hope of saving or pro- longing the life of the patient, either by operation or other measures. The average duration of life in carcinoma, if unmolested, is from two to three years. (Senn.) Some authors place it at eighteen months to two years. The duration of life largely depends upon the malignancy of the tumor, its location, and the vitality of the patient. Life is finally extinguished as the result of metastasis, septic infection, exhaustion, or of encroachment of the primary or secondary tumor upon vital organs. Treatment. — All modern writers are agreed, that if operative CARCINOMATA. 527 treatment of carcinoma is to be successful, it is of the utmost import- ance that it be undertaken early in the history of the disease. Carcin- oma in its earliest stages has a benign period, and if removed at this time has no more tendency to recur than other epithelial tumors which are of benign character. This is exemplified in the early excision of carcinoma of the lip, which if thoroughlj' removed is seldom followed by recurrence. Cylindrical and glandular carcinoma may also be as successfully treated by excision, provided the operation can be made under the same favorable conditions. Senn believes that carcinoma of the breast and of the uterus yield as satisfactory results if operated upon at an early period,— while the disease is still local in its manifesta- tions, — by the removal of the entire organ, as does excision of the car- cinoma of the lip. The first c^uestion to be decided in every case of carcinoma is, Can it be cured by a radical operation, or has it pro- gressed in its course so far as to admit only of palliative treatment? If operation is decided upon, the knife should be used with a bold and fearless hand, and the entire organ affected should be excised, when practicable, and as much of the surrounding healthy tissue removed as can be done with safety. Operation is sometimes recommended as a palliative measure, for the relief of pain, and for the purpose of removing necrotic tissue and a disgustingly-foul ulcerating sore. A radical operation in those cases in which it is impossible to re- move all the locally-infected tissue, or in which the lymphatic glands are involved or secondary carcinoma has developed, can be of no cura- tive value, but it may prolong the life of the sufferer for a few months, and this for various business and family reasons is sometimes exceed- ingly desired by the patient. Senn gives the following conditions under which a radical opera- tion is contra-indicated: "First, extreme senile marasmus; second, ex- tensive local infection; third, regional infection beyond the reach of complete removal of all the infected tissues; fourth, general infection; fifth, the co-existence of another disease which in itself will prove fatal in a short time." The great majority of all carcinomata presented to the surgeon for treatment have passed the stage when a radical operation would ac- complish anything more than temporaiy relief. It is a sad commen- tary upon the art of the surgeon that poor suffering humanity so dreads the knife of the operator that, if the disease is seen in time to save life by an operation and this is advised as the only safe course, the great majority will decline, or procrastinate until it is too late to be of benefit. But, when they realize this fact, they are then not only will- ing to submit to an operation, but sometimes demand that it be done, even at the risk of their lives while upon the operating-table. 528 SURGERY OF THE FACE, MOUTH, AND JAWS. The wound following an operation for the removal of carcinoma should be immediately covered with integument. If this cannot be accomplished by drawing the edges of the wound together by sutures, a flap of skin should be raised in the immediate neighborhood, suffi- cient to cover it; or, if this is not practicable, skin-grafting after the method of Thiersch may be resorted to. Healing of the wound by first intention is exceedingly desirable, and every effort should be made to secure it. The application of caustics, arsenic, chlorid of zinc, etc., as a radi- cal method of treatment, is not to be recommended, except in those cases in which the patient will not submit to excision; their use, how- ever, even under such circumstances, should be restricted to small- sized carcinomata of the skin. The removal of cancerous growths by the aid of caustics is much more painful than by excision with the knife, while the patient is under the influence of local or general anesthetics. The operation by caustics also requires much more time both for the removal of the tumor and for the healing of the wound, while the cos- metic effect is not so good, as it invariabl}- leaves a large scar. Palliative treatment in the non-ulcerative form consists of opium to relieve pain, and local applications of lead-water and tincture of opium, or other soothing remedies. In ulcerative carcinoma the sur- face may be dusted with iodoform and morphia; cocain solution painted or sprayed upon the surface will also relieve the pain. The fetor of the discharges may be lessened by the use of carbolic acid solu- tions, phenol sodique, cinnamon water, or a solution of chloral. The employment of dry boric acid dressings is also valuable for the same purpose, as they favor rapid drying of the discharges, and prevent putrefaction. REVIEW. CHAPTER XLIX. What is the essential factor in the production of all forms of epithelial neo- plasms? Have the influences or agencies which impart innocency and malignancy to these growths been discovered? How may the causes be divided? What is the essential cause of the disease? Which is the most frequent origin of the essential cause? About what per cent, have their origin in post-natal influences? What are these influences? How may such a tumor-matrix produce carcinoma? What is the result of transplanting mature and embryonic tissue? CARCINOXIATA. 529 What is the most prominent predisposing cause of carcinoma? What are the agencies which produce these conditions? How is heredity manifested? What reason is there for believing that such tendencies may be transmitted in certain families? In how many generations did Broca trace the disease? Does the evidence of Broca and other writers prove the hereditary trans- mission of the disease? If not, why? What do statistics prove in reference to hereditary transmission of carci- noma? What features in the clinical history of carcinoma point to micro-organisms as a possible cause of the disease? What were the chief difficulties in the way of demonstrating the tubercle bacillus? Has a cancer bacillus been demonstrated up to the present date? What would be the effect of such a discovery upon the teaching of to-day as to the origin of carcinoma? Is the presence of an epithelial tumor-matrix always productive of a carci- nomatous growth? What are the exciting causes of carcinomatous growths? How do local lesions produce the disease? About what per cent, of cases are ascribed by patients to injury? How soon does the disease follow the injury? Can injury alone produce the disease? Are extensive injuries necessary to excite the tumor-matrix to active growth ? How may inflammatory lesions and wounds become the starting point of carcinoma? How do senile tissue-changes cause the development of such neoplasms? What tissue-changes were observed by Thiersch in the lips of old persons? What is the most common exciting cause of the disease? What is tlie evidence of this fact? Where are these localities? How may decayed teeth and salivary calculus become exciting causes of cancerous growths? How may warts and moles become the starting-points of carcinoma of the skin? How may tubercular lesions of the skin cause the disease? Why is a correct and early diagnosis in carcinoma imperative? Is such a diagnosis readily made? What are the difficulties which surround the diagnosis? Under what circumstances does the diagnosis become impossible? What are the points which must be considered in the diagnosis? What is the most reliable evidence of the carcinomatous nature of a tumor? How may an infectious swelling be differentiated from a malignant tumor? How does the age of the patient assist in making a diagnosis in suspicious tumors? In what locations are carcinomata more liable to occur in men than in women? In what locations do they more often occur in women? Of what diagnostic value is the slow or rapid growth of the tumor? What point should be remembered in the differential diagnosis between carcinoma and an infective swelling? - 35 530 SURGERY OF THE FACE, MOUTH, AND JAWS. What form of infective swellings may be mistaken for carcinoma? Is the infection of the lymphatics an important symptom? What other diseases produce this symptom? What is the cause of the dilation of the superficial veins? What is the cause of the edema? Are tenderness and pain characteristic symptoms? In what stage of the disease do they become prominent? What is one of the most characteristic symptoms of carcinoma? W'hat forms of ulcerating tumors are frequently mistaken for carcinoma? What is the typical appearance of an ulcerating carcinoma? What characteristic sign appears upon section of the tumor? What is the constitutional efifect produced by carcinoma? Upon what does the prognosis of carcinoma depend? What is the prognosis of carcinoma of the skin? Under what circumstances could a favorable prognosis be given? In what class of cases does recurrence usually take place? At what stage of the disease is there no hope of saving or prolonging the life of the patient? What is the average duration of the disease? How is death finally brought about? Upon what point in the treatment of carcinoma are all modern writers agreed? How is the fact demonstrated that carcinoma has a benign period? What is the first question to be decided in every case of carcinoma present- ing for treatment? What should be the character of operative treatment? Under what conditions may an operation be resorted to as a palliative measure ? What value has a radical operation when lymphatic infection has taken place, etc.? Name the five contra-indications for operation named by Senn. How should the wound be treated after excision of the tumor? By what means may this be accomplished? Under what circumstances may the use of caustics be recommended? Which method is the most painful, and which gives the best results? What is the palliative treatment in the non-ulcerative stage? How may the ulcerating stage be treated? How may the fetor of the discharges be overcome? CHAPTER L. CARCINOMATA (Continued). The varieties of carcinoma which are of the greatest interest to the student of oral surgery are those which appear upon the integument of the face, upon the Hps, the oral mucous membrane, the tongue, and the salivary glands. Fig. 222. •^1 *s-, >•■>■ C.\RCiNOM.\— Epithelioma— Geser.\l Type of this Form of Growth. X 50. The varieties of carcinoma which are found affecting the super- ficial surfaces of the skin, the mucous membrane, and the tongue, as well as those which attack the glandular structures of these tissues, are commonly classed under the head of epithelioma. (Fig. 222.) This 531 53^ SURGERY OF THE FACE, ilOUTH, AND JAWS. term came into use before it was discovered that all forms of carcinoma are epitheliomatous (epithelial) growths, and was originally applied to a form of cancer located in the epithelial tissue of the skin. Fig. 223 is from an epithelioma of the skin of the abdomen. Fig. 224 illus- trates the microscopic appearance of chimney-sweep's cancer of the scrotum. Carcinoma of the Skin.- — Scjuamous-celled carcinoma (epitheli- oma of the skin) may develop in any portion of the body where a squamous or stratified epithelium may be found, but it is most fre- quently located in those portions where the skin and mucous mem- FiG. 223. Epithelioma of Skin (Abdomen). X 500. brane come into relation with each other, and at which point there is a transition from the stratified to the columnar form of epithelium. Carcinoma of the skin differs histologically from the benign forms of epithelial tumor (papillomata) in the fact that it is not confined to the epithelial tissues of the skin, but passes the boundaries of the basement membrane, and involves the surrounding connective tissue. Accom- pan3-ing this invasion of the connective tissue there is developed a CAKCINOiMATA. 533 peculiar arrangement of tlie epithelial cells kno\\n as "cell-nests," or "epithelial nests." These tumors usually make their ap]5earance upon the surface of the skin, either as warty growths, as slight cracks or fissures covered by a scab or crust, or as flattened tuljercles. The base is hard, the mar- gins indurated, and the tumor sometimes slightly elevated above the surrounding skin. In all these forms, ulceration sets in early. Some- times the ulcer will possess raised, rampart-like edges : in another form, Fig. 224. Epithelial nests lormed by iiNEV-SwEEP's Cancer of Scrotum. (T. Charters White.) instead of raised edges, the margins will be sharply defined; while occasionally, in still another, the edges will be undermined. The ulcer- ation which takes place is due to a defective blood-supply of the cells forming the central or oldest portion of the initial tumor, which results in their death. The tendency of primary carcinoma of the skin in the ulcerative stage, when left to itself, is to spread, and to involve extensive areas of tissue, or to form fungous niasses, or by gigantic granulations to form large cauliflower-like excrescences. Accompanying these conditions 534 SURGERY OF THE FACE, MOUTH, AND JAWS. is a foul, fetid discharge, in which are found small masses of dead tissue, cell debris, and blood. In its most malignant form, the surrounding tissues, either skin, muscle, or mucous membrane, are quickly invaded and destroyed, while the bone even is attacked and rapidly destroyed by erosion and necrosis. Cartilage alone resists the invasion of the disease. Fatty degeneration is the most common retrograde change that takes place in carcinoma of the skin. Colloid degeneration is more Fig. 225. Carcinoma — Epithelioma— showing Pearl or Colloid Bodies. X 75. rare. (Figs. 225 and 226.) In the warty form the processes which project from the skin are sometimes quite horny in their hardness. Histologically all of these varieties of carcinoma of the skin are identical in their structure. Sections of these neoplasms so cut as to include the edge of the ulcer and the adjoining tissue also, will show the surface epithelium dipping down into the connective tissue be- neath, in the form of long projections, "columns," or "plugs. The tissues about these epithelial projections are infiltrated with epithelial CARCINOJIATA. 535 cells (Sutton), while scattered among these projections and within them in various locations, are found those "peculiar concentric cellu- lar bodies" designated as epithelial nests. A peculiarity of the epi- thelial projections is that they have no limiting membrane, and that many of the larger projections branch and unite with neighboring col- umns, forming a sort of net-work or reticulum. "Cell-nests" are a peculiarity of all forms of skin carcinoma, but though the size of the Colloid degene Caiciiionm cells IcLifiierating. A-SHOWINL. CuLLOlD Dt epithelial projections and the number of the cell-nests may vary in the different forms of the disease, the general plan of the extension of the tumor is the same in all. (Fig. 227.) The locations in which this form of carcinoma is found are the face, the lips, the eyelids, the buccal aspect of the cheeks, the esopha- gus, the edges of old scars, and various other portions of the body which are not of especial interest in this connection. Carcinoma of the Face. — The face is the most frecjuent location of carcinoma of the skin. Out of 740 cases of tumors of all kinds, sub- 536 SURGERY OF THE FACE, MOUTH, AND JAWS. jected to operative treatment, O. Weber found 133 cases of carcinoma of the face, or 17.97 per cent. It occurs more frequently in men than in women. A". Ziemssen coUected 948 cases of carcinoma of the skin; of these 739 (77.95 per cent.) were in men, and 209 (22.05 P^'' cent.) were in women, showing the disease to be about three and one-half times more frequent in men than in women. The period of life in which carcinoma of the skin is most common is between forty and eighty years of age. The age at which it has been most frequently seen is between fifty-five and sixty. Fig. 227. Av", Carcinoma OF Skin OF Nates. >; no. Reduced one-third. (After Senn.) a, hypertrophiedstiatum corneum ; *, growth of epithelial cells into subcutaneous tissue; c, epithe- lial nest in vascular connective tissue. Carcinoma of the skin, according to Thiersch, appears in two forms, — one a superficial ulceration (rodent ulcer), and the other pene- trates deeply into the tissues, and successively involves the different structures. This is called the deep-seated, penetrating, or polymor- phous-cell cancer. The superficial variety of carcinoma, "rodent ulcer," is almost always found upon the face, and is frequently preceded or accompanied by keratosis, a thickening of the epidermis, and the presence of such callosities as warts, horns, etc. Superficial carcinoma is characterized by the formation of scabs CAKCINOMATA. 537 or crusts, which may exist for a long time before any mahgnant ten- dency is manifested. They appear first as scales, slightly elevated above and somewhat darker than the surrounding skin. The surface is sometimes smooth and shining, and at others covered with slightly adherent scabs. The elevated spots are not sensitive, and when the crust is removed leave an exposed superficial excoriation. This vari- ety of carcinoma does not usually appear until after middle life, is ex- tremely slow in its development, is painless, and on this account does not cause any anxiety as to its nature, until it has assumed considerable dimensions. Histologically, if the tumor is composed of scjuamous cells it ap- pears from the beginning" as an infiltration with small epithelial cells, which, before ulceration occurs, fill the alveoli of the stroma. If it arises from the glandular appendages of the skin, the columnar epi- thelial cells will be found arranged in groups resembling the tubular glands. (Senn.) In the early stage of ulceration the ulcer is not deep; its surface is quite fiat and bounded by a pearl-colored rim, the shape often resembling a horn waistcoat button. (Warren.) The ulcerative process from this time progresses by an unequal extension in different directions, so that the surface of the ulcer presents a very irregular outline. In this form of the disease glandular infection usually comes late in the life-history of the disease ; for this reason operative procedures are more liable to prove curative than in other forms of carcinoma. In the superficial form the ulceration takes place rapidly, but it is confined to the skin; while in the deep-seated or penetrating form, be- sides spreading in various directions, it also extends downward, in- volving the tissues beneath its base regardless of their structure, be it connective tissue, muscle, or bone. Carcinoma of the face most often attacks the upper portions; the frontal and malar regions, the eyelids, and the nose. Frightful deform- ities are sometimes produced by the extension of the disease. \\ arren describes a case in which the disease originated in the scar of a gun- shot wound received in the civil war, and had destroyed the side of the nose, the eye, the ear, and the cheek, including the corresponding half of the upper and lower lips. Diagnosis. — In the diagnosis of carcinomatous growths of the face it must be borne in mind that there are certain diseases which may be located in the face, such as tuberculosis, syphilis, suppurative condi- tions of benign tumors, and retention cysts (Senn), which may mislead even careful observers. Tuberculosis of the skin of the face may so nearly resemble carcinoma as to make it impossible to differentiate them without the microscope and inoculative experiments. Tertiary syphilitic affections of the skin may usually be differentiated from car- 53o SURGERY OF THE FACE, MOUTH, AND JAWS. cinoma by the presence of scars from syphilitic lesions which have healed. Doubt as to the nature of the disease may be cleared up by a resort to anti-sj^philitic treatment for a few weeks, when improvement will soon be manifest if the disease is syphilis. Prognosis. — ^The superficial variety of this disease in its early stage gives all the evidence of a benign growth, but there is a period in its history when for some unexplainable reason it suddenly takes on a malignant form, and the superficial variety of the disease is changed to the penetrating or deep variety. The shght malignancy of these ulcerating forms of the disease is thought to be due to the feeble re- productive power of the small epithelial cells, but Warren "thinks it more probable that there are other factors to be considered, such as the anatomical seat of the disease, and, possibly, the nature of the para- site, — if there be one, — which caused it." The prognosis is much more tmfavorable in the deep-seated vari- ety of the disease than in the superficial form, as the ulceration spreads ■ rapidly, and results in extensive destruction of the various tissues sur- rounding it in a remarkably short space of time. Warren looks upon the region of the nasal process of the superior maxilla as one of the most dangerous and "important strategic points" in cancer of the face, for the reason that carcinoma originating here, or encroaching upon the inner margin of the orbit, may suddenly involve the lymphatics leading to the base of the skull. He looks upon the disease as incur- able after it has once passed the margin of the orbit. Recurrence is the rule, though occasionally a permanent cure takes place. If the dis- ease does not return in five years, the cure may be considered as per- manent. Treatment. — The operative treatment of carcinoma of the face, to be successful, must be undertaken at a period prior to its infection of the lymphatics of its neighborhood. The tendency of the disease to extend toward the orbit, and involve the eye, makes it imperative that operative interference should take place before the orbit is reached. The eyelids and the side of the nose are quite frequently the seat of the disease, and sometimes extensive operations are required for its re- moval. The defects left by the removal of the cancerous growths are to be remedied by plastic operations and skin-grafting. When the lower eyelid has to be removed, the defect may be most satisfactorily remedied by Dieffenbach's method. Carcinoma affecting a portion only of one ala of the nose may be removed by cutting out a wedge-shaped piece of the entire thickness of the ala, and closing the defect by taking a flap from the opposite side of the nose, after the method of Langenbeck (Figs. 228, 229), or from the face, after the manner of Esmarch (Fig. 230). Thiersch grafts should be used to cover the wound left by the removed flap. When CARCINOIIATA. 539 the tumor involves the bridge of the nose and the bone lias l^econie infected, an extensive operation becomes necessary, rec|uiring the re- moval of the bony framework, and sometimes of considerable portions Partial Rhinoplasty by taking a Flap from the Opposite Side of the Nose. (After Langenbeck.) Fig. 229. Partial Rhinoplasty Completed. (After Langenbeck.) Fig. 230. Partial RHIN0PLAST^■ ijy taking a Pedunculated Flap from the Face along the Base of THE Nose. (After Esmarch.) of the nasal mucous membrane, as well as the integument. In those cases where the tip of the nose and the nasal apertures have not been involved in the operation, Konig's flap operation will correct the defect in an admirable manner. (Figs. 231, 232, 233.) \'\'hen all of the nose 540 SURGERY OF THE FACE, MOUTH, AND JAWS. has been sacrificed, Thiersch's operation for restoring the lost organ may be resorted to. (Fig. 234.) The excision of carcinomatous growths in other portions of the face should be performed with the same desire for thoroughness. In Fig. 231. Konig's Rhinopl-\sty. J, 4, flap for building nose, including skin, periosteum, and a thin slice of bone; b, flap used to ver flap o, and to furnish integument for the entire defect ; c, defect caused by excision of tumor. Fig. 232. Konig's Rhini rned downward ; b, lower end tastened in place > ;at d is left free, and to it flap b is sutured. ith catgut sutures. The skin at the top removing these tumors, it is better to sacrifice a Httle healthy tissue, and gain a successful issue of the operation, than to insure a speedy recurrence by carrying the incision so close to the growth that some portion of the infected tissue is left behind. The defects caused by the operation should be remedied by bringing the edges of the wound to- CARCINOMATA. 541 gether with sutures, or by a flap operation, and when this is not possi- ble, by Thiersch skin-grafts. Recurrence is to be looked for, and repeated operations may be required to eradicate the disease; but so long as lymphatic infection has not taken place and there is no evidence of other than local disease, there is hope of a final cure. Fig. 233. KoNiG's Rhinoplasty. a. b. defects over the frontal bone ; c, flap b which covers the bony surface of flap a, and furnishes the cutaneous covering for the entire defect, sutured in place. Fig. 234. Rhinoplasty Warren mentions a case of a gentleman who allowed a cancer to- grow upon the left side of the nose until it involved the skin of that side, and a portion of the right side. The disease returned three times. Finally the left half of the nose and the nasal process of the superior maxilla were excised, and the cavity thus left was covered by a flap taken from the forehead. The disease did not return after this, the fourth operation. 542 SURGERY OF THE FACE, MOUTH, AND JAWS. REVIEW. CHAPTER L. What varieties of carcinoma are of the greatest interest to the student of oral surgery? What term is usually applied to those varieties of carcinoma which affect the superficial structures of the skin, mucous membrane, and glandular structures of the mouth? To what form of cancer was this term originally applied? In what portions of the body may the squamous-celled carcinoma be found? Where is it most frequently located? How does carcinoma of the skin differ histologically from the benign epithelial tumors? How do these tumors usually make their appearance? What is the condition of the base and margins? What are the variations in the appearance of the ulcerated surface? What is the cause of the ulceration? In the ulcerative stage of the disease, what are its tendencies? What accompanies these conditions? Describe the conditions in the most malignant form of the disease. How is cartilage aiifected by the disease? What is the most common retrograde change in this form of carcinoma? What sometimes characterizes the warty form of carcinoma? Describe the histologic structure of carcinoma of the skin. What is a peculiarity of the epithelial projections? What is a peculiarity of all skin carcinomas? In what locations is this form of carcinoma found? What is the most frequent location of carcinoma of the skin? What percentage of carcinomatous tumors are found in the face? In which sex is it most frequently found? In what proportion are men more subject to this disease than women? At what period of life does the disease usually develop? At what age is it most frequently seen? In what forms does it appear? Where is the superficial variety usually found? By what condition of the skin is it often preceded? By what condition is superficial carcinoma of the skin characterized? How do these crusts first appear? What is the condition on removing the crust? At what period of life does this form appear? What is the character of its growth, etc.? What is the histologic character of the tumor when composed of squamous cells? What, when arising from the glandular appendages? How does the disease appear in the early stage of ulceration? What is the character of its progress? When does glandular infection take place in this form of the disease? What are the differences in the ulcerative process in the superficial and deep- seated varieties? CARCINOMATA. 543 In what location of the face is carcinoma most frequently seen? What disease may be mistaken for carcinoma of the face? How may doubts in reference to tuberculosis and syphilis be cleared up? What is the prognosis in the superficial varietj'? What is it in the deep-seated variety? In what portion of the face is carcinoma considered most dangerous? Is the disease liable to recur? At what period should operative treatment be made? By what means are the defects left by the removal of the growths to be remedied? By what method may the lower eyelid be restored? By what method may portions of the ala of the nose be restored? By what means may the bridge of the nose be restored? By what means may the entire nose be restored? What should be the character of all operations for carcinoma of the face? How is recurrence to be treated? CHAPTER LI. CARCINOMATA (Continued). Carcinoma of the Lip. — Carcinoma situated in the lip, like carci- noma in general, rareh' develops tmtil after middle life. It is most frequently seen between the fortieth and sixtieth years. The deep-seated, penetrating, or polymorphous-cell carcinoma is typically represented in carcinoma of the lip. The disease usually commences at the border of the lip, at the junction of the mucous mem- brane with tlje skin (Fig. 235), and its first appearance is either in the Fig. 235. form of a small papule, or as a flat crust (Warren) which frequently scales off only to be re-formed again. It rarely occurs at the angles of the mouth, or upon the upper lip. (Fig. 236.) The general appear- ance of the disease in its early stage is that of a superficial infiltration of the vermilion border of the lip, having a well-defined indurated out- line. Later ulceration of the indurated area takes place in the center, from which may be squeezed the atheromatous contents of the exposed epithelial cell-nests. It then presents a shallow, ulcerated surface with circular outline and elevated overhanging edges. (Fig. 237.) With. 545 Epithelioma of the Upper Lip— Early Stage. (After Sutton.) Fig. 237 546 SURGERY OF THE FACE, XtOUTH, AND JAWS. few exceptions, the disease if left to itself involves the greater portion of the lip or destroys it altogether, and the chin, cheek, and lower jaw are successively implicated. The submaxillary lymphatic glands on the affected side at this time are enlarged, and become adherent to the maxillary bone, which gives the appearance of malignant disease aris- ing from the periosteum of the jaw. The disease sometimes appears as a warty excrescence, which may involve the entire lip. (Fig. 238.) Fig. 238. "Variety. (After Sutlon.) Occasionally it may occur that the lip will be affected upon one side, and the lymphatic glands of the submaxillary region upon the other. No explanation of this peculiarity is yet forthcoming. (Sut- ton.) Sometimes the glands are afi'ected upon both sides, but this is usually an expression of rapid extension of the primary disease to the opposite side of the lip, with implication of the mental and submental tissues, of the most serious character, and suggests an early termination of the life of the patient. In the later stages of the disease, the sub- CAKClNdMATA. 547 maxillarv triangles and the neck l)eeonie greatly enlarged, food is taken with difficnlty, and the patient slowly dies from marasmus, sepsis, or a general infection and dissemination of the disease, or from hemor- rhage. Metastatic nodules are sometimes found in the internal or- gans. The disease usually terminates fatally in from three to five years, though occasionally it runs a much shorter course. Carcinoma is much more frequent in the lower than in the upper lip. It is common in men, but exceedingly rare in women. Konig's statistics place the proportion of males to females as 20 to i. War- ren's reported cases make the proportion 19.25 to 1, while those of Lortets' show the proportion to be 7.6 to i. W. Roger Williams, in a recent contribution to the British Ulcdical Joiinial regarding primary neoplasms of the lip, states that of 13,824 primary neoplasms of all kinds, consecutively under treatment at St. Bartholomew's University College, Middlesex, and St. Thomas Hos- pitals, during the last sixteen to twenty-one years, 352, or 2.5 per cent., originated in the lips. These included 7297 cancers, of which 332 grew from the lips, or 4.5 per cent. Of the 352 lip-neoplasms, 340 sprang from the lower lip, thus: epithelioma, 329 (males 326, females 3); papil- loma, 7 (males 4, females 3); angeioma, 3 (male i, females 2); cystoma, r (male). Only 12 originated in the upper lip, thus: epithelioma, 3 (male i, females 2); sarcoma, 4 (males 2, females 2); angeioma, 3 (male i, females 2); papilloma, i (female); fibroma, i (male). Carcinoma is oftener seen upon the left side of the lip than upon the right. It may also occur upon the median line. (Warren.) The cause of the disease is often ascribed to some form of chronic irritation. Irritation from the constant use of tobacco, and particularly of the pipe, has been thought by many to be a prolific cause of carcinoma of the lip. Mason Warren ascertained that out of 77 cases of carcinoma of the lower lip, all but seven were in the habit of smoking: out of this number four were women, and three of them were in the habit of using a pipe. It is a significant fact in the observation of the writer, that the side of the lip most often the seat of the disease is the side of the mouth upon which the pipe has been habitually carried. It has also been observed that smokers who are subjects of carcinoma of the lower lip have frequently been in the habit of using clay pipes, the stems of which have not been prepared to prevent the irritation of the lip so common in using new ones. J- C. Warren mentions a case of carcinoma of the lip occurring in a Nvoman, — the only one coming under his observa- tion, — and she was in the habit of smoking. The carcinoma in this case was in the upper lip. The writer has seen one case of the disease in an Irish woman, seventy vears old, an habitual smoker, and who 548 SURGERY OF THE FACE, MOUTH, AND JAWS. always used a clay pipe. In this case the neoplasm was in the lower lip upon the left side. The pipe was carried between the teeth upon the left side, the stem of which had worn for itself a notch in the upper and lower teeth, in which it ixsted. The writer has also seen several cases of carcinoma of the lip in men where the evidence was unmistakable that the disease had started in an abrasion or excoriation caused by the stem of the pipe resting upon the lip. Fig. 239. Epithelioma ok the Lower Lip becinninc I^ a Fissire ( -^ftei Sutton.) The formation of the neoplasm is frequently preceded by a crack or a fissure (Fig. 239), or an eczematous patch in the margin of the lip (Senn), or by an injury. Out of 145 patients suffering from carcinoma of the lip, Koch attributed 1 5 to traumatisms. (Senn.) Diagnosis. — In the diagnosis of carcinoma of the lip, there is dan- ger of confounding eczematous conditions with the superficial spread- ing form of carcinoma in its early state. The exposure of the deeper layers of the skin, the papillomatous appearance, the raw surface and serous transudation all tend to render the diagnosis somewhat difficult. The presence of an indurated condition of the deeper structures of the skin or of the mucous membrane, associated with these symptoms, marks the carcinomatous character of the growth, while the absence of the induration marks its eczematous character. A primary syphil- CARCINOMATA. 549 itic sore might mislead in the diagnosis, were it not remembered that it develops very rapidly, and is associated at a very early period in its history with glandular infection. The opposite of these conditions marks even the most rapid growth of carcinoma. A secondary syph- ilitic lesion of the lip usually originates in the mucous membrane of the mouth, and infects the lip by extension. (Senn.) Primary tubercu- losis of the lip is a very rare affection. It may be distinguished from Fig. 240. ■:• .". -•? ;. Cj -- ;- V ■• • : •. >•«*• r • - ¥ Round-celled infiltration. Epithelial nests. CaRCINO.MA— EpiTHELIOM.\ OF LlP. (A.) X 50. carcinoma by its more diffuse character from the beginning, and the absence of the induration so characteristic of carcinomatous growths. Doubts as to the character of the tumor can be cleared up by the microscopic character of the tissues, and by inoculation experiments. Hgs. 240, 241 show the histologic structure of epithelioma of the lip. Prognosis. — The prognosis is usually favorable in those cases in which an operation is made in the earl)^ stage of the disease — while it is still superficial. But an opinion upon the matter should be guarded even here. Complication of the lymphatic glands is usually consid- S50 SURGERY OF THE FACE, MOUTH, AND JAWS. ered as an exceedingly unfavorable sj'mptom, and the utility of an operation for their removal, if much enlarged, is open to serious ques* tion. When of small size and freely movable, they should be extir- pated, together with as much of the surrounding tissue as may be safely removed. Occasionally the operation for even the superficial form of the dis- ease is quickly followed by recurrence. Warren relates the case of a "physician who applied for operation about three months after the first Fig. 241, y degener; lion. Carcinoma— Epithelioma of Lip. (B.) X 100. appearance of the disease. There was no return in the lip, but a gland under the jaw began to enlarge six months later, and the patient suc- cumbed eighteen months after the first appearance of the disease." Fortunately such cases are exceptional, but there are few surgeons of many years' practice who have not had like unfortunate experiences. In those cases in which the glandular structures are involved to any considerable extent, and the jaw has become infected, operations are of very little value. Treatment. — Carcinoma of the hp in its early stages may be readily CARCmOMATA. 551 removed by a V-shaped excision of the Hp. (Fig. 242.) When the loss of tissue has been comparatively small, not more than half the width of the lip, the defect may be remedied by simply bringing the edges of the wound together and suturing them in that position. This leaves at first a puckered condition of the mouth (Fig. 243), but the lower lip gradually elongates, and after a time a fairly good lip results. Fig. 242. Excision ui thl 1 w l i i i Cakcinumv (After Esmarch.) Fig 243 Oper-\tion LuMiLLii L { Vftci Ebiiiaich.) Fig 244 Suturing after Excision o Lower Lip for Carcinoma Another method is that of Celsus. After removing the tumor by the V-shaped incision, horizontal incisions are carried out from the base (apex of the V) for a sufficient distance to enable the wound to approximate more easily. In cases of superficial carcinoma of the border of the lip involving only the mucous and submucous tissues, an incision may be m.ade at one angle of the mouth, and carried through the lip to the opposite 552 SURGERY OF THE FACE, MOUTH, AND JAWS. oral angle, removing the entire margin of the lip. The mucous mem- brane is then reflected over the surface of the wound, and sutured to the margin of the skin. (Fig. 244.) In cases requiring the removal of more than half of the width of the lip, it should be done by a curved incision, the convexity being downward. The mucous membrane may then be lifted and sutured Fig. 245. Langenbeck's Method of Restoring thh Lower Lip after Excision for Carcinoma. ( \fter Lingenbeck ) Fig. 246. 1! Operation Completed. (After Laiigenbeck over the surface of the wound to the margin of the skin. This leaves a semilunar defect in the border of the lip, but in the course of time it gradually diminishes. When the entire lip has to be excised, a new lip must be made by a plastic operation. Langenbeck has devised a method of accomplishing this. (Fig. 245.) The lower horizontal margin of the defect is prolonged on either side by incisions, which pass along the remainder of the lower lip, around the angles of the mouth and into the upper lip ; each portion of the lip is mobilized and drawn together by sutures. Fig. 246 shows the operation completed. CARCINOMATA. 553 The objection to Langenbeck's second method is the fact that the border of the new lip cannot be covered with mucous membrane, and that cicatricial contraction takes place to a certain extent during the healing of the wound. Hueter's operation for the restoration of the lower lip is also a valuable method, and is described as follows: The margins of the defect in the lip are brought together by sutures, and an incision is made in the cheek horizontally outward from the angle of the mouth, involving the entire thickness of the cheek; the mucous membrane on each side of the new wound is reflected a little and then united to the skin by sutures. Fig. 247. Cheiloplastn (Alter Bruns.) Fig. 248 Operation Com Operations for the removal of tumors located in the upper lip do not differ for partial excision from those practiced upon the lower lip. In those cases requiring the excision of the entire upper lip, the defect may be cured by the method devised by Bruns, which consists in fash- ioning two quadrilateral flaps out of the entire thickness of the cheek and upper lip, on each side of the mouth, and turning them down so that their upper borders can be sutured together in the median line. (Fig. 247.) Finally the edges of the wounds left upon each side are to be brought together with sutures, and their size diminished as much as possible. (Fig. 248.) In all operations upon the face the utmost care should be exercised to reduce to a minimum the deformities and scars left by surgical 554 SURGERY OF THE FACE, MOUTH, AND JAWS. operations and accidents. Plastic surgery has been brought to such a high degree of perfection that there are few defects in connection with the human face which cannot be restored with fairly good cos- iTietic and functional results. REVIEW. CHAPTER LI. At what period of life does carcinoma of the lip develop? What form of this disease is found in the lip? Where does it usually begin? Where are its first manifestations? Describe its general appearance in the earlier and later stages of the disease. At what period does infection of the glands take place? What peculiarity of gland infection is sometimes observed? What conditions indicate an early termination .of the life of the patient? How is life finally terminated? What is the duration of life in carcinoma of the lip? In which lip is carcinoma most frequent? In which sex is the disease most common? In about what proportion are males more affected than females? Upon which side of the lip is it most often seen? To what condition is the disease often ascribed? What would statistics seem to prove? Does clinical observation substantiate these figures? By what is the disease often preceded? What diseases occurring on the lip may be mistaken for carcinoma? What conditions of the surrounding tissues mark carcinoma? How may carcinoma be dififerentiated from syphilis? How may tuberculosis be differentiated from carcinoma? What is the prognosis of carcinoma of the lip? Are operations of value in cases of extreme involvement of the glandular structures and of the jaw? What form of operation is recommended for small carcinomata of the lip? What was the method of Celsus? Describe Langenbeck's operations for restoring the lower lip. Describe Heuter's method. How may the defect caused by the removal of the entire upper lip be cured? Describe Bruns's operation. CHAPTER LII. CARCINOJNIATA (Continued). Carcinoma of the Buccal Mucous Membrane and Jaws. — The buccal mucous meni1)rane is covered by pavement epitlielium several layers in thickness. The superficial layers represent the squamous or flat epithelium, and the deeper layers the cylindric or columnar variety. Carcinoma of the mouth has its origin, as in the skin, either in the stratified eDithelium or in the cjdindric epithelial cells of its glandular appendages. Two forms of carcinoma are found in the mucous membrane as in the skin, viz: the superficial and the dccp-scatcd varieties. The only differences between these forms are those due to peculiarities in the structural arrangement of the epithelial cells, and to the tissues being constantly bathed with moisture. The superficial form of the disease follows the clinical history of the affection as found in the skin, being confined to the superficial layers of the epithelium, and manifesting no tendency to involve the glandular structures of the mucous membrane. The first manifestation of the deep-seated variety of the disease is usually the formation of a small, hard nodule within a tubular gland of the mucous membrane. The epithelial cells forming the center of the nodule undergo fatty degeneration, and finally, when ulceration takes place, the atheromatous mass can sometimes be squeezed out, leaving a deep central depression upon the surface of the ulcer. The base of the ulcer is always indurated, while the edges are raised above the sur- rounding surface. The ulcer shows no tendency to heal, but, on the contrary, spreads in all directions. Microscopically the tumor pre- sents a tubular structure, the tubules being lined with columnar epi- thelial cells. This form of the disease is most frequently located in the mucous membrane of the cheek, but it may originate in the gums, the soft palate, the tonsils, and the pharynx. The disease often starts near the angle of the mouth, and e.\.tends backward upon the cheek; or it begins in the gingivo-buccal fold, and occasionally in the center of the cheek upon a line indicated by the occlusion of the upper and lower teeth. The disease is rarely seen at the angle of the mouth or in the upper lip, which is explained by the fact that the mucous glands are less 555 556 SURGERY OF THE FACE, MOUTH, AND JAWS. numerous in these locations than in other portions of the oral mucous membrane. Carcinoma of the oral mucous membrane has been thought by some observers to be due to the irritating effects of tobacco, as produced by smoking, but as there are no statistics presented to corroborate the statement, it is presented merely as an opinion. Carcinoma of the mucous membrane of the cheek is sometimes preceded by the ap- pearance of a patch of "leucoma" or leucoplakia, — a chronic super- ficial inflammation of the mucous membrane or the tongue, charac- terized by the presence of pearly-white or bluish-white patches upon the surface of the gums, mucous membrane, or tongue. The affection is rare in women or in individuals under twenty years of age. It is due to some chronic form of irritation, such as the smoking of a pipe, or the wearing- of artificial teeth. Wallenbers: believes it is caused most fre- First bicuspid. Mixed Carcinoma of the Inferior Maxilla. (A.) quently by the irritation produced by the volatile and empyreumatic oils of tobacco. (Warren.) The writer has seen but three cases of leuco- plakia, all in men. In one the affection was upon the dorsum of the tongue near the center, the patch being the size of a quarter-dollar piece. This gentleman was forty years old, and a great smoker of cigars. It had caused no inconvenience, although it had been there for sev- eral years. In another case the disease was located in the left gingivo- buccal fold, but principally upon the gum, in a man past fifty years of age. The disease had been noticed for several years, and for more than a year past had been very troublesome, causing pain and smarting when acids, salt, or anything of pungent flavor came in contact with it. Operation was advised, but declined. Soon after this it took on ma- lignant symptoms, extending to the superior maxillary bone and the whole side of the cheek. Three years afterward he died from exten- sion of the disease to the lymphatic glands of the neck. The third case was similar to the second in its location. This patient was a physician forty-five years of age, and appreciated the danger of procrastination in an affection of this character. The presence of the disease was dis- CARCINOMATA. 557 covered by accident during an examination of his teeth. It was evi- dently in its early stage of development, as its presence had never been recognized by the patient. He demanded an immediate operation, and the diseased tissue was removed down to the bone. Eight years afterward there had l^een no recurrence. Fig. 250. Epitheliu Carcinoma— Mixed— OF Infekior Maxilla. (B.) Fibrous Portion. X 70. The fact that carcinoma of the cheek frequently appears along the line of the occlusal surfaces of the superior and inferior molars, oppo- site decayed or roughened buccal surfaces of the teeth, or upon the tongue or gums, irritated by the same means, leaves no doubt that these agencies are prolific exciting causes of the disease. Carcinoma may appear in the superior or inferior gum, but it is most frecjuently seen in the mucous membrane covering the lower 558 SURGERY OF THE FACE, MOUTH, AND JAWS. alveolar process. The disease usually arises in connection with a cari- ous tooth in which the cavity of decay has extended beneath the mar- gin of the gum, leaving a sharp or jagged edge ; or in relation with a devitalized and carious tooth, the crown of which has been lost, leav- ing the root with rough margins which irritate the gum. Fig. 251, The affection in this location is characterized by an exceedingly rapid progression. The bone is infected in a very short space of time, and this condition is often mistaken for the primary affection. The disease as it progresses in the lower jaw has a tendency to spread in one direction toward the cheek, and in the other toward the tongue. Figs. 249, 250, 251, 252 are photographs of a mixed carcinoma of the inferior maxilla and its histologic structure. When located in the su- CARCINOMATA. 559 l^crior maxilla the alveolar process is quickly eroded, and the antrum is invaded, leaving a foul ulcerating cavity, which discharges an of- fensive pus. The erosion of the bone as it takes place in either maxilla causes loosening and exfoliation of the teeth in the infected region. Carcinoma of the Antrum. — Some of the most distressing cases of carcinoma coming untler the observation of the writer have been Fig. 2S2. INI'EKIOR M.A those which involved the antrum of Highmore, either by extension from the mouth, or in which the disease was primarily located in this sinus. The latter form of the disease occurs in individuals past mid- dle life. The first symptom complained of is pain in the jaw, for which no adequate cause can be assigned. (Sutton.) Pain is some- times entirely absent. Later there is observed a slight fullness in the 560 SURGERY OF THE FACE, MOUTH, AND JAWS. infra-orbital region, with perhaps edema of the lower eyelid, occasion- ally a mild degree of exophthalmos; the skin becomes discolored, and later a carcinomatous ulcer breaks through the skin of the cheek near the inner canthus of the eye, or into the mouth through the alveolus of a recently extracted tooth. Inspection of the mouth will also reveal extensive erosion of the palate process, and bulging of the roof of the mouth upon the affected side. If the case is operated upon at this period, it will be found, upon reflecting the cheek, that the disease has usually made such extended inroads upon the surrounding tissues as to have involved not only the palate process, but all of the bony walls of the antrum, penetrated to the muscles of the cheek, involving the skin, and implicating the contents of the orbit, making it necessary to remove the entire maxillar}' bone of the affected side, together with the infected tissue of the cheek and the contents of the orbit, leaving a yawning chasm which cannot be closed by plastic operation. The disease is very fatal, and life is rarely prolonged beyond a few months at most, but during that time the patient is spared much sufTering and discomfort as a consequence of the operation. Regional infection of the lymphatic glands is an early and conspic- uous feature of the disease when it involves the maxillar}- bones. Sut- ton calls attention to the fact that the infected lymph glands of the neck may attain an extraordinary size, while the ulcer upon the gum may be very small, not exceeding one cm. in diameter, thus tending to mis- lead the surgeon in his diagnosis. He further suggests that rapid- growing glandular enlargements located in the neck in persons past middle life should call for a careful examination by the surgeon "of the mouth and fauces, for small inconspicuous epitheliomatous ulcers, and with every care they sometimes escape detection during life." Carcinoma of the mouth affecting the mucous membrane of the cheeks and gum, and involving the superior maxillary bones, is an exceedingly rapid and fatal form of the disease, the average duration of life being about eighteen months. As a rule, these growths resent surgical interference. The insidious character of the tumor is such that it has usually passed the time when radical measures are available before its true nature has been discovered. Excision of the growth has almost always been followed by recurrence, for the reasons just mentioned. There would seem, however, to be hope of a permanent cure of the disease if it could be removed before regional infection had taken place. Treatment. — Surgical operations for carcinoma of the mouth, to be 01 real value, must be bold, and at the same time most painstaking. There is perhaps no affection with which these qualities of an operation are more imperatively demanded. Timidity or carelessness upon the part of the operator will result not only in a damaged reputation, but CARCINOMATA. 561 in what is of infinitely more serious consequence to the patient, — a quick recurrence of the disease. Radical operations for carcinoma of the mouth, particularly in those cases aiTecting the maxillary bones, will require external incisions. Operations conducted through the mouth for so grave an affection are of little practical benefit, as it is impossible to thoroughly trace the ramifications of the disease, or by any possibility remove infected submaxillary glands through this cavity. The writer had one unfortunate experience in his early practice in attempting to remove such a growth through the mouth. Thor- ough removal of the diseased tissue was impossible, and the patient's condition three months after the operation was worse than before. The surgical interference, on account of the imperfect removal of the carcinomatous tissue, and the irritation incident to the operation, seemed to stimulate the growth to most active cell-proliferation. Four months after the operation the patienr died. The incisions should always be made with reference to the least possible amount of disfigurement. When operating upon the upper maxilla, the incisions should follow the natural lines of the face as far as possible; in operations upon the lower jaw the lines of incision can be hidden in large part beneath the jaw. The extent and character of the particular operation in each individual case will be indicated by the location of the neoplasm and the extent of the infection. Partial ex- cisions of the superior maxillary bone may be done by the Nelaton operation or that of Guerin. Partial excision of the inferior maxilla may be accomplished by incisions passing through the median line of the lip and chin, and carried backward to the angle of the jaw beneath the lower border of the bone. Carcinoma of the Tongue. — According to Butlin, carcinoma of the tongue is confined to the squamous-celled variety, and he refutes the statement that the tongue is sometimes the seat of hard and soft carcinoma. Fig. 253 shows a vertical section of a circumvallate papilla of the human tongue. Carcinoma of the tongue is usually located upon the side or the dorsum, usually near the tip. The anterior half is much more fre- quently the seat of the disease than the posterior half, while it may be stated generally that the disease is usually located in some spot in its anterior two-thirds, the edges being more subject to the disease than either the dorsum or the under side. (Butlin.) The disease is always, even when upon the dorsum, distinctly located either upon one side or the other of the median line, but so far as statistics go, they do not show any distinct preference of the disease for one side over the other.- The disease may make its first appearance either as a blister, an excoriation, an ulcer, a fissure, a pimple or tiny tubercle, a warty 37 562 SURGERY OF THE FACE, MOUTH, AND JAWS. growth, or a nodule (Butlin) upon the surface or within the substance of the tongue. In the early stages of the disease the microscope shows that the tumor retains the papillary structure of the tongue upon its surface. But later, after ulceration becomes more extensive, infiltra- tion from the surface results in the production of epithelial prolonga- tions and the formation of epithelial "cell-nests" within the vascular connective-tissue stroma in typical concentric layers. (Fig. 254.) Causes. — The most frequent exciting causes of the disease are chronic irritation, from mechanical agencies, — rough or carious teeth, ill-fitting dental plates, — and the irritating influences of smoking Fig. 253, Vertical Section of Circumvallate Pap . OF Human Tongue. (T. Charters White.) tobacco. Besides these forms of irritation may be mentioned certain chronic inflammatory affections of the mucous membrane which pre- cede the formation of cancerous growths in the tongue, viz: leuco- plakia, ichthyosis, psoriasis, and syphilis. Symptoms and Diagnosis. — The disease usually runs a rapi-d course, the lymphatic glands of the neck soon become infiltrated, and death supervenes in from one to two years. Pain in carcinoma of the tongue is often quite sharp and severe, of stinging character, and sometimes reflected to the ear. As the disease advances, speech and deglutition become more and more embarrassed. Salivation is also a prominent symptom. The surface of the ulcer is sometimes covered with papillary growths, sometimes with sloughing, g-angrenous shreds of connective tissue. The indurated character of CARCINOMATA. 563 the cancerous growths of both base and margins remains throughout the course of the disease. The disease is more connnon in men than in women. Sutton places the proportion as 3 to i ; Senn, 7 to i ; Buthn nearly 6 to 1, and Barker, 6.35 to i. The disease is pre-eminently one of past middle life, being most frequent after the fortieth year. It has been recognized in patients as young as twenty-five, and as old as seventy-five years; the largest number afifected being between the ages of forty and sixty, the largest proportion beween forty-five and fifty. (Sutton.) Fig. 254. Epithelioma .-i- iiii- i.im.ii. i w riKLrtevs White.) X loo. The diseases which are most likely to be confounded with carcin- oma are syphilitic indurations and sores, tubercular nodules and ulcera- tions, warty tumors, traumatic ulcers, fissures, and actinomycosis. Syphilitic indurations- — gummata — of the tongue may be difTerentiated by the presence of other syphilitic lesions of the tongue or other por- tions of the oral cavity or of the body. Tubercular disease of the tongue is rarely seen in other persons than those suffering from pulmonary tuberculosis. A tuliercular ulcer c'oes not possess the in- 564 SURGERY OF THE FACE, MOUTH, AND JAWS. durated base and margins characteristic of carcinoma, and its surface is covered with fungous granulations. Actinomycosis is an exceed- ingly rare disease in man. The microscope is the only means of posi- tive diagnosis. Prognosis. — The prognosis of carcinoma of the tongue is always unfavorable. When the disease is left to itself, it usually terminates the life of the patient in from one to two j'ears. Operation in the cases which are unmistakably carcinoma tends to relieve pain and distress, and prolongs life for a short time; but the end is nearly always recurrence in the remaining portion of the tongue, or secondary disease in the lymphatic glands of the neck. The pro- longation of life by an operation has been variously estimated at from five to eight months. The operation itself is always a dangerous one; hemorrhage and septic pulmonary conditions being the chief causes of fatalities from the operation. Treatment. — Radical operations for the treatment of carcinoma of the tongue are to be preferred to treatment by caustics. The applica- tion of caustics, as a rule, seems only to stimulate the proliferation of the "cancer-cells," and renders the growth of the tumor more rapid and malignant. As a preliminary to all operations upon the tongue, Billroth re- commended a careful disinfection of the entire cavity of the mouth. This process to be of real value will require a painstaking cleansing of the teeth by the removal of all salivary deposits and alimentary debris, followed by the free use of antiseptic solutions. To draw the tongue forward, and to hold it in position during the operation, a stout ligature should be passed through the tip at the median line, and the ends tied. Hemorrhage is often very troublesome . in operations requiring partial or complete excision of the tongue ; to guard against accidents from this cause many surgeons are in the habit of ligating one or both lingual arteries, or a temporary ligature may be so placed upon the tongue as to entirely prevent the bleeding during excision of any por- tion of the anterior half, or even two-thirds of the organ. This is ac- complished by passing a well-curved needle armed with a strong dou- ble silk ligature, through the middle of the tongue, as near its base as possible. The ligature is then cut close to the eye of the needle, and each thread tied separately, one upon each side if the whole tongue is to be rendered bloodless. (Figs. 255 and 256.) If but one half is to be excised, the ligature need be tied only upon the side to be re- moved. The ligatures may be left long enough to extend outside the mouth, and the ends tied, as they are useful in drawing forward the root of the tongue and giving a good view of that portion of the orgaiu which is so necessary when the disease is located near its base. CARCINOMATA. 565 Senn advises the use of an elastic ligature in the form of a piece of small drainage tube, about twelve inches long, doubled and passed through an opening in the base of the tongue at the median line, made by tunneling the tissues with a pair of hemostatic forceps. The tube is to be cut in the center, and each piece tied at opposite sides of the tongue sufficiently tight to arrest all hemorrhage. The jaws must also be opened to their fullest extent by means of a suitable mouth-gag. Fig. 255. ^^> ^^AV *:; Temporary Constriction of One-half of the Tongue. (After Esrnarch and Kowalzig.) Fig. 256. Temporary Constriction of the Whole Tongue at its Base. (.■^UerEsmarch and Kowalzig.) The operation for partial or complete excision of the tongue may be done by several methods. On account of the hemorrhage which so often follows the use of the knife or scissors, the ecraseur (Fig. 257) or the galvano-cautery wire were formerly substituted by many sur- geons for this operation, but of late the great majority have gone back- to the use of the knife or scissors, as the other means did not always prevent hemorrhage when the excision took place near the base of the tonsrue. 566 SURGERY OF THE FACE, MOUTH, AND JAWS. Small carcinomatous tumors may be readily removed through the mouth by a V-shaped incision made by a blunt-pointed bistoury or scissors, the portion to be removed having been previously seized with double-pronged forceps, and the tongue drawn well forward. All bleeding vessels are then secured, and the edges of the wound brought together with sutures. (Figs. 258, 259, 260, 261.) Fig. 257. Chassaignac's Chain Ecraseur. Fig. 258. Removal of Tumor of the Tongue— Insertion of Traction-Suture. (Aft Operation through the mouth is applicable for the removal of the anterior third or half of the tongue. When a lateral half is to be re- moved it may be accomplished in the following manner: Two stout ligatures are passed through the tip of the tongue, one on each side of the median line, which are to be used to draw the organ forward; the tip is then raised, the frenum cut with scissors, and the tongue dis- sected from the floor of the mouth as far back as is necessary. The tongue is then split upon the median line, from before backward, freed CARCINOMATA. 567 from tlie underlying parts by tearing witli the finger, and the posterior section made with the I'cnife or scissors. Whitehead removes the entire tongue through the mouth, but does not practice preliminary ligation of the lingual arteries ; these ves- sels he secures as thev are divided. Fig Excision 01- Tumor. {After Esmai'cli.) Fig. 260. Tying of First Suture. (After Esmarch.) Fig 261 Operation C Langenbeck secures access to the base of the tongue by an incis- ion made at the angle of the mouth and carried downward to the thy- roid cartilage ; through this incision any infected lymphatic glands, or the submaxillary, may be removed. Division of the digastric and hypoglossus muscles is then made, and the lingual artery tied. The jaw is next divided at the line of the incision, and the segments sepa- rated, after which the mucous membrane is severed from the inner sur- 568 SURGERY OF THE FACE, MOUTH, AND JAWS. face of the posterior segment as far back as the anterior pillar of the fauces. Through this opening it is not only possible to reach the base of the tongue, and amputate it at this point, but also to reach the tonsil and the soft palate, and reinove them when necessary. (Fig. 262.) Billroth modified this operation by dividing the soft tissues and the jaw at both angles of the mouth, and turning down the central segment. Regnoli devised a method in 1838, later modified b}^ Billroth, which provides free access to the base of the tongue without division of Amputation of the ENBECFw s Method. Amputation of the Tongue according to Regnoli-Billroth. the lower jaw. An incision is made along the inner surface of the lower border of the jaw from angle to angle, and the cavity of the mouth opened from beneath. The tongue is then seized and drawn down and forward, until its base is within easy reach. (Fig. 263.) This operation has the advantage of affording free access to infected glands, the establishment of adequate drainage, and of allowing the best antiseptic treatment of the wound. Kocher's method is to make an incision "from the under border of C.\RClNO.\t.\TA. 569 the lower jaw near tlie s_\nipliysis, in the direction of the anterior behs- of the digastric nmscle to the liyoid bone; thence backward to the an- terior border of the sterno-cleido-mastoid muscle; then upward along it to or above the angle of the jaw." The flap is then raised as far as the lower border of the jaw, and an incision made through the floor of the mouth as close to the bone as possible, and through this opening the tongue can be drawn down and amputated. (Fig. 264.) I^ocher's operation requires preliminary tracheotomy. The advantages of this operation are the facility with which infected glands may be reached and removed and the lingual artery tied. It also permits the pack- ing of the fauces with sponges or gauze, thus preventing the entrance of blood into the trachea, and facilitates antiseptic treatment of the mouth. The tracheotomy tube should remain for several days, the patient to be fed through an cesophageal tube. Fig. 264. Kocher's Incision in Amputation of the Tongue Senn recommends the passing of two traction sutures through the base of the tongue, which are then brought out of the mouth, in cases of amputation of the entire organ, and are used afterward as a means of fixing the stump for a few days in its proper position. He thinks this is an exceedingly important precaution. The after-treatment consists of establishing drainage and as thorough antiseptic conditions as the nature of the case will permit. A saturated boric acid solution, or the Thiersch solution, are the most valuable antiseptics for use in these cases. , Carcinoma of the Salivary Glands. — Primary carcinoma of the salivary glands is not a disease of very common occurrence, but it is exceedingly malignant. As a primary aft'ection it is more common in the parotid than in the other salivary glands. Secondary carcinoma of the submaxillary glands associated with carcinoma of the lower lip, the oral nuicous membrane, the gums and 570 SURGERY OF THE FACE, JIOUTH, AND JAWS. the tongue, are of common occurrence. The primary form of the dis- ease is rarely seen in these or the sublingual glands. Carcinoma of the parotid gland ma)' be of either the acinous or the tubular variety. In the acinous form the disease begins as a proliferation of col- umnar epithelial cells in an individual acinus or lobule of the gland. Its malignant character is marked by the scantiness of the stroma, its rapid growth, and the early infection of the lymph glands. Fm;. 265. Mixed Tumor of PAkoxm Gland. (A ) (Heterogeneous structure.) X 50. The tubular variety begins in the tract of the salivary duct, and appears in the form of epithelial pearls or "cell-nests" of columnar epithelia, which arrange themselves in a manner similar to tubular glands. These tubules multiply and extend into the substance of the gland. Carcinoma of the parotid gland does not appear until middle life. Its general clinical history is that of carcinoma of the face. In persons CARCINO^CATA. 571 of fift}' years of ago or more, a rapitl-growing tumor of the parotid gland whicli infiltrates the skin, and finally ulcerates, is with few ex- ceptions a carcinoma. Neoplasms of heterogeneous structures are more freqtiently seen in the parotid gland than tumors of a pure type. Figs. 265, 266, 267 are made from sections taken from three different locations in the same tumor, and nicely illustrate this point. Treatment. — Carcinoma of the parotid gland calls for early and complete extirpation, with all surrounding infected tissues. The na- FiG. 266. Mixed Tumor of the Parotid Gland. (B.) (Heterogeneous structure.) X 50. ture of the operation is somewhat serious, and requires, on account of the important vessels in the neighborhood, most careful dissection. The extirpation of the gland results in permanent paralysis of the face, and this result should be made perfectly clear to the patient before an operation is undertaken. Senn suggests that when a large area of skin is infected, the dis- eased portion should be included within two elliptical incisions, the lower angle of which should be so placed that it will he directly over 572 SURGERY OF THE FACE, JIOUTH, AND JAWS. the point at which the external carotid artery must be Hgated. The temporal artery shotild be ligated upon the distal side of the tumor, and secured by compression forceps upon the proximal side. Careful dissection of the entire mass is required, and must be carried down to the styloid process. As soon as the external carotid arter}^ is exposed it should be grasped with the hemostatic forceps, the tumor then re- moved and the artery tied afterward. The wound made by such an Fig. 267. Mixed Tumor of the Parotid Gland. (C.) (Heterogeneous structure.) X 50- •operation necessarily leaves a large opening which cannot, be closed ■except by a plastic operation. This may be accomplished by taking a flap from the forehead or the scalp, leaving it attached at its base by a pedicle until union has taken place in its new position. The wound left by removing the flap should be at once covered by skin grafts after Thiersch's method. In those cases in which the skin can be preserved Senn exposes the gland by a curved incision, the convexity looking downward, and extending from the mastoid process to near the malar eminence. The tumor is then removed by the method just described. CAKflXOMATA. 573 RE\'IE\V. CHAPTER LII. What is the character of the epitheHum of the mucous membrane? In what portions of the mucous membrane may carcinoma be located? How many forms of carcinoma are found in the mucous membrane? How do they differ from carcinoma of the skin? What is the clinical history of the superficial variety? Describe the cause of the deep-seated variety. Where is this form of the disease most frequently located? In what other locations is it found? In what locations is it rarely seen? By what conditions is carcinoma of the cheek sometimes preceded? What is leucoplakia? What is thought to be the cause of leucoplakia? How may it terminate? What are the active causes of carcinoma? In which jaw is carcinoma of the mouth most common? How may carious teeth and roots cause carcinoma? How is the disease characterized in this location? How does it progress? What sinus may be involved when the disease is located in the upper jaw? How are the teeth affected by the disease? At what period of life does the disease occur? What are the symptoms of carcinoma of the antrum? Describe the clinical course of the disease. When does regional infection take place? What relation does the size of the ulcer bear to lymphatic infection? What is the character of carcinoma of the cheek and gums involving the maxillarj' bones? What is the average duration of life in this form of the disease? Are they amenable to surgical treatment? At what period in the history of the disease does surgical treatment give the best results? What should characterize the surgical treatment? Can the disease when affecting the maxillary bone be successfully removed through the mouth? What rule should be followed in making the external incisions for removal of the disease in the upper jaw? How may partial excision of the superior maxilla be made? What lines of incision should be adopted in partial excision of the inferior maxilla? What form of carcinoma is found in the tongue? Where is it usually located? Which part of the tongue is mo,st frequently affected? In what forms may the disease first make its appearance? What is the microscopic character? What are the exciting causes? What is the character of the course of the disease? 574 SURGERY OF THE FACE, MOUTH, AXD TAWS. How long- does the patient usualh- live after the establishment of the disease? What are the symptoms of the disease? In which sex is the disease most common? What is the proportion? At what period of Hfe does it appear? What are the hmits of age at which the disease has been noticed? Between what ages does the largest number occur? What diseases may be mistaken for carcinoma of the tongue? How may syphilitic indurations be differentiated? How may tuberculosis be diflferentiated? How may actinomycosis be differentiated? What is the prognosis of carcinoma of the tongue? What is the value of operation in these cases? How long is life prolonged by an operation? What are the causes of fatalities following operation? How does the application of caustics affect the disease? What preliminary steps should be taken in all operations upon the tongue? How guard against severe hemorrhage? Describe the method of temporary ligation of the lingual arteries. What is Senn's method? What methods of operation are introduced to prevent hemorrhage? Are these methods still practiced? Describe the operation for remos'ing small tumors. When is operation through the mouth applicable? What method may be employed to remove a lateral half of the tongue? By whose method ma}' the entire tongue be removed through the mouth? How does Langenbeck secure access to the base of the tongue? How does Billroth modify this operation? Describe the Regnoli operation as modified by Billroth. Describe Kocher's method. What preliminary operation is required? What recommendation does Senn make in reference to the stump of the tongue after amputation? Is primary carcinoma of the salivary glands common? What is its character? Which of the salivary glands are most often aft'ected with primary carci- noma? Under what conditions is carcinoma of the salivary glands common? What varieties of carcinoma are found in the parotid glands? How does the acinous form of the disease begin? What marks its malignant character? Where does the tubular variety of the disease begin? How are the epithelial cells arranged? At what period of life does the disease occur? What is its clinical history? What should be the character of the operation in carcinoma of the parotid? Is this a serious operation; and if so, why? What condition of the face results from extirpation of the parotid gland? How does Senn operate for extirpation of the gland when a large area of skin is involved? How should the wound be closed? What method does Senn employ when the skin can be preserved? CHAPTER LIII. MESO ELASTIC TUMORS. Fibromata. In the connective-tissue group of tumors are included all those neoplasms which arise from tissues developed from the mesoblastic layer of the germinal disk of Pander. The tumors which compose this group have their genesis in a matrix of misplaced connective-tissue cells, of embryonic type, of either pre-natal or post-natal origin. Tumors of this class may be, as with the neoplasms of the epithelial group, either benign or malignant in their character; ihnocency and malignancy depending upon the stage of differentiation reached by the tumor-cells. Cells of high differentiation will produce innocent tumors; cells of low differentiation will result in the development of malignant tumors. Under the head of benign mesoblastic tumors may be placed fibroma, lipoma, myxoma, chondroma, osteoma, angioma, neuroma, and lymphangioma. Some of these, however, have a ten- dency under favoring conditions to undergo sarcomatous transforma- tion. Under the head of malignant tumors of mesoblastic origin are placed the various forms of sarcoma. The tumors of the mesoblastic type which are of most frequent occurrence in connection with the face, mouth, and jaws, are 'the fibromata, chondromata, osteomata, angiomata, and sarcomata. The other forms are so rare in these locations that their presentation mav be omitted. Definition. — Fibroma (Lat. fibra, a fiber, and Gr. o.ua, a tumor). "A Fibroma is a benign tumor, composed of mature fibrous tis- sue produced from a matrix of fibroblasts." Fibromata are the most representative of the mesoblastic tumors, and are the most common. They are to be found in all parts of the body where connective tissue and blood-vessels form a part of the structure. The chief locations of fibrous tumors are the periosteum, espe- cially of the jaws, the skin, the uterus, the ovaries, the neurilemma of -the nerves, the terminal or peripheral ends of nerves, — where they form 575 576 SURGERY OF THE FACE, MOUTH, AND JAWS. painful tubercles within the subcutaneous tissue, — the rectum, and the naso-pharynx, — where the)- form polypi. Origin. — Fibromata have their origin in a matrix of congenital fibroblasts, which for some reason have been arrested in the process of dififerentiation during the development of the embryo, and have re- mained in a more or less embryonic condition in the connective tissue until some influence, either local or general, has stimulated their dor- mant energies and powers of cell proliferation into activity. It is thought by some authorities that the matrix may sometimes be of post- natal origin, as it frequently occurs that such tumors develop in the Fibroma— Keloid— IN the Lobe of thk Pinna, associated with an Ear-ring Puncture. (After Sutton.) cicatrices following wounds and traumatic injuries of any form (Fig.. 268), and in the regenerative process following suppurative inflamma- tion. Ziegler says, "The fibromata are developed from proliferous con- nective-tissue cells." Histologically, a fibroma is composed of interlacing bands or- bundles of connective tissue, often showing upon the cut surface a concentric arrangement of the connective-tissue fibers in various parts of the tumor. These whorls are arranged around blood-vessels. The bundles are composed of long, slender, fusiform or spindle cells, closely packed together (see Fig. 269). They usually possess a distinct cap-- sule, which renders it an easy matter to enucleate them. JIESOBLASTIC TU.MORS. 577 Fibromata may arise from either the periosteum or the endosteum. Fibrous epulides are usually periosteal or peridental in their origin, while antral fibromata are endosteal growths arising from the muco- periosteum lining the maxillary sinus. Varieties. — Fibrous tumors are sometimes dense and firm as a tendon, — known as hard fibroma; at others soft and spongy, and desig- FiG. 269. Fibrous Tumor froi\ a, fusiform nucleus THE Antrum of Highmore. X 450. ; d, younger nucleus of an oval shape : Fig. 270. (After D.J. Hamilton.) :, isolated fibroblast. H.ARD Fibroma fr nated as soft fibroma. In the former variety, the intercellular tissue is very scanty, and the fibrillse are arranged in compact wavy bundles, or in whorls. (Fig. 270.) On section they are smooth, glistening", dense, and of grayish-white color. The latter variety, known as soft fibroma, consists of a more or less loose, spongy, fibrous tissue, abundantly sup- plied with blood-vessels. Upon the character of the fibrous tissue which enters into the formation of these growths will depend the gen- eral appearance of the tumor, which may be more or less yellowish, 3S ■ 578 SURGERY OF THE FACE, MOUTH, AND JAWS. glistening, semi-transparent, or gelatinous. The ordinary nasal pol_v- pus is a typical illustration of this form of fibroma. Degenerative changes frequently take place in these tumors, viz: myxomatous, cal- careous, colloid, ulcerative, and sarcomatous. Occasionally changes of a higher degree take place. In fibrous tumors arising from the periosteum or the endosteum, ossification is most frequently seen. Whether this is really the result of changes produced by tendencies of the tumor itself, or is the result of misplaced osteoblasts, has not been demonstrated. These tumors are usually encapsulated, and are easily enucleated, except when inflammatory adhesions are present. Causes.- — The essential cause of the disease is the presence within the connective tissue of a matrix of embryonic fibroblasts. The excit- ing causes are chronic irritation, traumatic injuries, and inflammatory conditions. Fibroma of the Gums. — Fibroma of the gums (epulis) is a tumor composed of fibrous tissue, situated upon the gum, and having its ori- gin from the periosteum of the alveolar process or from the peridental membrane. These growths will usually be found associated either with a tooth having a carious cavity at the gingival margin, or with a retained root of a carious tooth which has been covered by the gum, but which has caused a constant irritation of the gingival tissue by its rough edges; or by some preceding inifammatory affection which has left a chronic condition of congestion in the alveolar periosteum or the peridental membrane. Tumors of this character are of slow growth, painless, and usually composed of firm fibrous tissue, covered with the gingival mucous membrane. (See Fig. 250.) In form they may be sessile or peduncu- lated, usually the latter. In size they may vary from a walnut to a man's fist. Sessile tumors of large size exert great pressure upon the alveolar arches, changing the form of the maxillae, and crowding the teeth out of position. The lips are sometimes protruded, the cheek distorted, and when located in the region of the posterior molars, the palate may be encroached upon. In the pedunculated form the tumor may attain such a size as to preclude the possibility of closing the mouth. The writer once assisted in the removal of such a tumor, which was located between the first and second inferior left molars, upon the buccal aspect of the gum, in a girl thirteen years of age. The tumor was as large as a Messina orange, somewhat pear-shaped in form, and" attached at the small end by a narrow pedicle. Fibromata associated with the gurris and the teeth are of frequent occurrence. The simple fibroma is the most common, and it rarely reaches a size larger than a walnut. Pure fibroma is occasionallv seen MESOBLASTIC TUMORS. 579 in this location, but in the experience of the writer, fibro-angioma, fibro-chondroma, and fibro-osteoma are much more common. Fibrous tumors in this location are prone to ossification. Degenerative changes also frequently occur in them, ulceration and sarcomatous transforma- tion being the most common. The disease is one which occurs in early life, and is rarely seen after the thirty-fifth year. Diagnosis. — In the diagnosis of fibroma of the gum, the fact that hyperplasia of the gingival festoons and fungoid conditions of the dental pulp (hernia) may so closely resemble fibroma as to be readily mistaken for that tumor, must not be overlooked. Hyperplasia of gum festoons may be distinguished by its very broad pedicle, and by its re- taining the general form of the festoon. Fungoid pulps (hyperplasia of the pulp, the result of hernia) may be distinguished by the growth being attached by a constricted pedicle, which arises from the central canal of the tooth. Fibroma of the gums is usually a hard tumor covered by a healthy appearing mucous membrane; its surface is smooth, sometimes glis- tening. When large they may become injured by the closing of the teeth, and the injury result in ulceration. Sometimes they have a purplish color, showing an abnormal supply of blood-vessels, when they are classed as fibro-angioma. Tumors of this character are fre- quently erectile. The fibro-chondromata and the fibro-osteomata are very dense, and the latter contain numerous small spiculas of bone. Prognosis. — The prognosis of fibroma of the gum is favorable. The character of the tumoi' is benign. But in a tumor of long stand- ing there is a possibility that a sarcomatous degeneration may have set in, consequently the opinion in such cases should be guarded until a positive diagnosis can be made by the microscope. In simple fibroma, recurrence does not take place after excision. Treatment. — Local remedies for the cure of fibroma, which stimu- late the absorbents, are worse than useless, as they only cause irrita- tion; and irritation may result in sarcomatous degeneration. Radical cure of a fibroma of the gums can only be efifected by excision of the alveolar process of the jaw. To accomplish this operation it is first necessary to extract a tooth upon each side of the tumor, and then with a small Hey's saw (Fig. 271), or small circular saw, revolved by the surgical engine, divide the bone to the base of the alveolar process upon each side of the tumor; then by a horizontal incision of the bone with the circular saw or a metacarpal saw uniting the perpendicular incisions, the section is removed; the same end may be accomplished with chisel and mallet. Resection of the jaw is only admissible when the character of the tumor is undoubtedly malignant. S8o SURGERY OF THE FACE, MOUTH, AND JAWS. Antiseptic mouth lotions, used with persistence, is the only treat- ment of the woiuid recjuirecl. Hemorrhage may sometimes be troublesome, but this is usually controlled by packing the wound. Fibroma of the Jaws. — Aside from fibroma located upon the gum, fibromata of the jaws are rare. The maxillary periosteum and bone are the most frequent location of fibroma. Fig. 272 is made from a plaster cast of a tumor of this character located in the lower jaw. These tumors usually arise from one or the other of two situations, either the maxillary sinus or the alveolar processes of either jaw. Tumors of this class located within the antrum are capable of causing great destruction of surrounding bony tissue by pressure-atrophy. Fig. 271. Fibroma — Sessile — of the Lower Jaw. Fibromata in this location are usually very slow in their growth, and their presence is not recognized until the neoplasm has filled the antrum, and has caused expansion and thinning of the walls of the sinus. They may also encroach upon the nasal passages, and com- pletely fill them. Senn reports such a case, which is illustrated by Figs. 273, 274, 275. Heath describes a case in which the tumor "projected upward into the orbit, destroying the floor of that cavity, and protruding from its inner margin forward into the cheek. It had also destroyed the anterior wall of the. antrum, and displaced the malar bone forward and outward; inward it projected into the nose beneath the middle MESOBLASTIC TUMORS. 581 turbinated bone, and downward it made its appearance on the surface of the alveolar process in the form of a rounded mass, destroying the floor of the antrum in the neighborhood of the anterior molar teeth. Behind, the tumor appeared in the zygomatic fossa by the absorption of the outer surface of the tuberosity of the superior maxillary bone." Listen and Paget both record cases of similar character. Fibrous tumors arising from the alveolar process of the upper maxilla sometimes attain such size as to encroach upon the facial and palatal surfaces, causing pressure-atrophy, and crushing in the walls of the antrum, though not actually involving the sinus. On the other hand, although the tumor is located upon the alveolar process, it may secondarily involve the antrum, destroying its walls, enter the nasal fossa and penetrate the palatal process, projecting into the mouth. Fig. 273. Enormous Fibro OR Maxilla. (.A.) (Alter Senn.) Tumors of this character arising from the alveolar process of the lower jaw may attain a very considerable size, causing loss of bone- tissue by pressure-atrophy, and great deformity of the face. A growth of this character located in the anterior portion of the lower jaw. which came under the observation of the writer several years ago, had so dis- placed the six anterior teeth and the bicuspids of the right side that they projected at a right angle to their normal position outward and beyond the lower lip. The tumor seemed to grow from the lingual stirface and base of the alveolar border, and in its growth the entire S82 SURGERY OF THE FACE, MOUTH, AND JAWS. alveolar process in that location seemed to be lifted up and rolled out- ward. The privilege of taking a photograph or a cast of the mouth was declined by the patient. Fibromata of the jaws associated with the alveolar process are usually sessile, generally lobulated and round or oval in form, covered ■by the gum-tissue of the part, and are slow of growth and painless unless irritated. Tumors of this class located in the jaws do not as a rule cause local infection nor metastatic deposits. Diagnosis. — In fibroma of the antrum it is by no means always possible to make a correct diagnosis until after the removal of the tumor. Pain and tenderness are usually absent except when the tu- FiG. 274. Distortion of the Dental Arch cal'sed bv Enormous Fibroma. (B.) (After Senn mor is intimately associated with the trunk of a nerve of sensation, upon which it causes pressure, or when it is the subject of infection and inflammation. The great diiBculty in the diagnosis arises from the similarity in the symptoms of fibroma, chondroma, and slow-growing sarcoma. Prognosis. — The prognosis is favorable even though extensive IIESOBLASTIC TU.MORS. 583 loss of bone-tissue may have resulted. Recurrence does not take jilace after enucleation has been performed. Treatment. — Surgical treatment consists in the entire removal of the growth. This may be accomplished by enucleation. Enucleation of a fibroma of the superior maxilla is best accom- plished by external incision, which must be governed as to location and extent entirely by the size of the tumor. In operations upon the in- ferior maxilla for the removal of a large tumor, care should be exer- cised to leave at least a narrow rim of bone at the base of the jaw rather than to make a complete exsection of the bone. The advantages of this will be readily understood. Small tumors may be removed through the mouth. Fig. 275. [E Upper Maxilla, showing Condition of Parts IM^1EDIATEL^■ after Excision OF Tumor. (C.) (After Senn.) Fibroma of the Skin. — Fibrous tumors frequently appear upon the face, neck, and trunk of the body. Their growth is very slow and painless, and they rarely exceed the size of a filbert nut. They appear first as enlargements in the connective tissue of the skin; as they grow the skin is elevated by the tumor, which projects more and more until the skin at its base becomes constricted. The weight of the tumor causes elongation, which results in the formation of a pedicle. The tumor contains in its center the principal artery, which sometimes, in consecjuence of an injury or of te.xtural change (Senn), becomes stran- 584 SURGERY OF THE FACE, MOUTH, AND JAWS. gulated by a thrombus, when gangrene results, and the tumor is cured spontaneously. Fibrous tumors of the face are most often sessile, and are easily enucleated by an incision over the surface or at the base. A mole is a flat fibroma of the skin, of congenital origin. These tumors vary in size from a pin-head to growths three to four inches in diaiBeter. The increase in size progresses until puberty, when they usually become stationary. It has long been recognized that these growths are very prone to take on carcinomatous and sarcomatous degenerations. As a consequence of this tendency, their early removal should be advised. If the area of skin is large that must be sacrificed in their removal, the defect can be remedied by a skin flap or Thiersch skin-grafts. REVIEW. CHAPTER LIII. What neoplasms are included in the connective-tissue group of tumors? From what do these tumors have their origin? How are they classed? What condition of structure gives innocenc}' or malignancy to these tu- mors? What tumors are classed as benign? What tumors are classed as malignant? ■ Give the definition of fibroma. What form of tumor is the most representative of the mesoblastic group? Where are they found? What is their chief location? What is their origin? By what other process may they originate? Describe their histologic structure. From what tissues do they usually arise? From what tissues do fibrous epulides arise? What is the origin of antral fibroma? How are the fibromata classed? Describe the hard fibroma. Describe the soft fibroma. What degenerative changes may take place in these neoplasms? In which variety is ossification most likely to occur? What is the essential cause? What is the exciting cause? From what tissues do fibromata of the gum arise? With what conditions of the teeth are they usually associated? What is the character of their growth? Of what tissue are. they composed? What is said of their form and size? MESOBLASTIC TUMORS. 585 Are such tumors common or rare? What variety is the most common? What degenerative change is apt to occur in these growths? At what period of life do they most frequently occur? How may these growths be differentiated from hyperplasia of the gum fes- toons? How differentiated from fungous growth of the pulp? What is the appearance of fibroma of the gums? What other varieties are often seen? Describe the appearance of fibro-angioma. What is the character of a fibro-osteoma? What is the prognosis? Is this tumor benign or malignant? What form of degeneration may occur? Does recurrence take place after operation? Is local treatment of value? How may a radical cure be effected? Describe the operation. Under what conditions is resection of the jaw admissible? How may hemorrhage be controlled? In what tissues do fibromata of the jaws originate? In what particular parts are they usually found? What is the character of their growth? What sometimes results from fibroma of the antrum? What may be the extent of the deformity? What may be the extent of the growth and deformity when the tumor arises from the alveolar processes of the upper jaw? What is the result of tumors of this variety located in the lower jaw? Is the diagnosis of fibroma of the antrum difficult to make? What is the difference between the growth of fibromata and malignant tu- mors? Under what circumstances are fibromata painful and tender? What causes the difficulty in the diagnosis? What is the form of fibrous tumors associated with the alveolar processes? What is the character of their growth, etc.? Do fibromata cause glandular infection? What is the prognosis of fibroma of the antrum? Is the prognosis equally favorable when the neoplasm is located in the al- veolar processes? What should be the surgical treatment of these forms of fibroma? What should govern the location and extent of the external incision? In removing large growths from the lower jaw, what method is advised? In what locations are fibromata of the skin most common? What is the character of their growth? Describe their appearance. How may spontaneous cure take place? What is the shape of fibroma of the face? What term is applied to the common form of fibromata of the face? What is the variation in their size? When is their growth most active? What forms of degeneration occur in these growths? When should they be removed? How should large wounds be covered? CHAPTER LIV. CHONDROMATA. Definition. — Chondroma (xirM^poi, cartilage, "u-a, tumor). Chondroma is a cartilaginous tumor, — a tumor consisting of car- tilage. Chondromata are tumors composed histologically of hyaline carti- lage. They occur in locations, principally, where cartilage is normally found, viz: associated with the bones and within the cartilaginous struc- tures of the respiratory organs. They are also occasionally found in locations where cartilage has no normal existence. In the former case the growth may be due, as pointed out by Virchow, to the presence of embryonic or untransformed portions of cartilage remaining in the bones, and which later take on active cell-proliferation, thus becoming the starting-point of a tumor. The latter condition is explained by the modified theory of Cohnheim, of a misplaced matrix of embryonic chondroblasts in tissues where they have no legitimate presence, as, for instance, in the parotid gland, ovary, etc. Typical chondromata are found in the long bones, usually in rela- tion with the epiphyseal cartilages; consequently they occur most fre- quently in growing children and in young adults. The long bones of the hands and feet are especially liable to the affection. Fig. 276 illus- trates a remarkable case of this character published by Stendil. Chondromata may be described as slow-growing, painless tumors, firm to the touch, and always encapsulated. During their growth they displace the soft tissues, and cause absorption of the bone from which they spring, fashioning for themselves large cavities in which they rest. Calcareous, mucoid, and myxomatous degenerations frequently occur in the cartilaginous tumors. They are prone to ossification and to sarcomatous transformation. For the latter reason these tumors have always been looked upon with more or less suspicion.. Fig. 277 illustrates the histologic structure of an ossifying chondroma. Injuries of a traumatic nature seem to be most prolific in causing the disease. Rachitis is a frequent exciting cause. Sutton observes that "it is a curious circumstance that the tissue of a chondroma re- CHONDROMATA. 587 sembles, histologically, the bluish, translucent epiphyseal cartilage characteristic of progressive rickets." A chondroma consists of cartilage and connective tissue; the con- nective tissue, however, is found in limited quantity. The tumor is composed of numerous lobes of varying size, which are separated from one another b}' the connective tissue. Occasionally the fibrous tissue Fig. 276. Chondromata IPLE— IN Lad Twent OF Age. (.\fter Stendil.; is largely in excess of the cartilage. Such tumors, are termed fibro- chondroniata. In size, form, and numbers the cartilage cells vary greatly in different tumors, and also in different locations in the same tumor. (Warren.) The tumor grows by additions to its external sur- face. When ossification takes place, it usually begins at the center of the tumor. These growths are sometimes inclosed within a real bony layer or capsule deri\ed from the bone-tissue in which they are formed. 500 SURGERY OF THE FACE, MOUTH, AND JAWS. Diagnosis. — A chondroma may be recognized by its lobulated form, which increases with the growth of the tumor, by its density, ex- cept in locations where mucoid or colloid degenerations have taken place, when fluctuation ma}' be present ; by the early age at which thev appear, and the tendency which they exhibit to become stationary at the age of puberty, and by the slow growth of the tumor and the ab- sence of pain and tenderness. The disease in the long bones is very often multiple, though indi- vidual chondromata are not uncommon. Its slow growth and tendency to multiple formations differentiate it from osteo-sarcoma. Chondroma may be distinguished from oste- FiG. 277. tHMMiR