Chapter XXVI

.)

_Cancrum oris_ has already been described in the chapter on Gangrene. The extensive destruction which it may cause is also described there. The condition, when seen and recognized early, has been successfully treated by local applications of bromine and the actual cautery. It is, however, a destructive and unpromising condition with which to deal, as it rarely occurs in healthy children, but usually in those with a constitution already vitiated by heredity or environment. (See p. 75.)

TUMORS OF THE FACE.

The parts described in this chapter may be the site of almost every tumor which is met with in any other part of the body; in addition to which there are two which are peculiar to the nose and adjoining tissues. These are _rhinophyma_ and _rhinoscleroma_. They have both been described briefly in the chapter on Tumors, and each is to be differentiated from the other, having a very different etiology.

_Rhinophyma_ consists of vascular engorgement, with hypertrophy, especially of the glandular and connective-tissue elements of the skin, which begins about the tip and the alæ of the nose, and produces disfiguring deformity. It is, however, at first, quite innocent in its character. It occurs most often in hard drinkers, and is to be regarded as an overgrowth, coupled with a large amount of secretion, of the sebaceous glands of that portion of the skin. This secretion is often so great as to escape and lead to the formation of scabs, as it dries, until more or less ulceration takes place. The nasal enlargement is rarely symmetrical, and is nearly always lobular, so that the overgrowth may consist of a series of nodules whose escaping secretion becomes offensive. The parts are often discolored, even to a purplish color, in consequence of venous stasis. Frostbite frequently predisposes toward it.

[Illustration: FIG. 419

Plexiform angioma of face; cirsoid aneurysm. Not benefited by ligation of external carotid. (Lexer.)]

[Illustration: FIG. 420

Illustrating ravages of rapidly growing vascular sarcoma of face, involving all the cranial and facial cavities. (Lexer.)]

Treatment in incipient cases may consist of a sort of massage, by which the overloaded glands are emptied. In more serious instances the diseased tissue should be extirpated, and either left to granulate or be covered by a plastic operation.

_Rhinoscleroma_ is a serious and fatal lesion, consisting of a parasitic invasion by a peculiar bacillus. It begins as a painless induration, either at the edge of the nostril or upon the upper lip, grows slowly, the tissue affected becoming firm and dense. The growth is usually lobulated, with fissures or excavations between the lobules, which may crack and give rise to a yellowish discharge that dries into crusts. While the affection may begin in the deeper parts of the nasopharynx its occurrence there is usually the result of extension from the anterior growth. The disease may occur either in the young or in the adult. A case illustrated elsewhere (see p. 55), for which I am indebted to Dr. G. W. Wende, proved fatal after a couple of years. In this country it is rare, but occurs frequently in some portions of Russia.

For treatment there is but little encouragement, least of all for operative intervention. Growths nearly always recur after removal.

In the cheek _cysts of Stenson’s duct_ and _dermoid_ tumors and cysts have often been observed near the parotid region. The so-called “fatty ball of Bichat” is occasionally the site of an angioma, which may press upon Stenson’s duct and be accompanied by calculus in the parotid gland, the superficial veins being much dilated. (Souchon.)

Fatty tumors, as well as sarcoma in this same tissue, are prominent. The most frequent tumors of the face are the _epitheliomas_ of the lip, nearly always of the lower lip, occurring oftener in men than in women. A growth of this character at this site is regarded as an expression of the result of irritation, which may be produced by a carious tooth or by constant friction of a pipe-stem, or from many other causes. It frequently develops at the site of an old chronic fissure. These growths spread from small beginnings, and if, when small, they were extirpated there would be fewer cases of cancer of the lip spreading to and involving the face and neck. Every ulcer of the lip whose base becomes indurated, and from which the syphilitic element can be excluded, should be excised, the ensuing defect being repaired by a plastic operation. (See above.)

[Illustration: FIG. 421

FIG. 422

FIG. 423

FIG. 424

FIG. 425

FIG. 426

FIG. 427

FIG. 428

FIG. 429

FIG. 430

FIG. 431

Utilization of rectangular flaps.]

OPERATIONS UPON THE FACE AS A WHOLE.

The tissues composing the face are extremely vascular, hence hemorrhage is profuse and hemostasis should be exact. By virtue of this same rich blood supply the process of repair is prompt and satisfactory, if sources of infection be avoided. Patients here, more than anywhere else, desire a minimum of scar. Incisions, then, should be so planned as to permit the utilization of the natural folds or grooves of the face. They should also be so made as to avoid injury to main trunks of vessels and nerves, as well as to Stenson’s duet. Sharp knives and the least possible bruising of the tissues help to ensure the desired result. When possible a subcutaneous suture should be employed. When this is not sufficient fine needles and fine suture material should be used. A reasonably short, clean wound upon the face, especially in the neighborhood of the mouth, should be protected from the air until it is dry, using a dusting powder and then covering with collodion. In extensive operations provisional or permanent ligation of the carotid may be necessary; usually the external branch will suffice. In every instance plastic repair should be made, as it will always be required after the excision of growths involving the surface.

Space does not permit of detailed or specific directions for all possible methods of plastic repair of facial defects, but Figs. 421 to 441 illustrate the principal methods which may be utilized in planning and sliding flaps which shall serve this purpose. These may be modified or combined to meet special indications.

[Illustration: FIG. 432

FIG. 433

FIG. 434

FIG. 435

FIG. 436

FIG. 437

FIG. 438

FIG. 439

FIG. 440

FIG. 441

Sliding rectangular flaps into desired position.]

It is often necessary to intermit the anesthetic because the operator must displace the mask in order to do his work. Souchon advises an apparatus by which most of this delay can be avoided. By means of a rubber bulb a current of air is passed through the bottle containing the anesthetic and then directed through a tip which is passed down in the pharynx through a nostril. This may be connected, if so desired, with a bag of nitrous oxide gas, which is illustrated in Fig. 442, and its use in Fig. 443.

Ligation with excision of a section of the external carotid has been suggested by Dawbarn as a means of cutting off the blood supply in _cases of inoperable malignant tumors of the face_, thus reducing their rate of growth. In tumors of the jaw, for instance, he would also tie the inferior dental artery, with its mylohyoid branch, just before it enters the inferior dental canal. He advises, also, the removal of one inch of the inferior dental nerve, thus avoiding pain and distress, occluding the artery on the less diseased side first, waiting for two or three weeks before attacking the more diseased side, for should there be noticeable benefit after operation on the more affected side many patients would be unwilling to be again subjected to the other operation. Other operations include those made upon the various nerves for relief of neuralgia or for nerve suture of divided trunks. These have been described in a previous chapter.

[Illustration: FIG. 442

FIG. 443

Souchon’s intranasal inhaler.]

OPERATIONS ON THE NOSE.

Plastic operations upon the nose appear to have been practised early in the history of surgery. The East Indians had a method by which the skin of the forehead was made to furnish a flap from which a new nose was created. This was known as the Indian method. It has been somewhat modified of late years by raising with the skin flap the periosteum, or, as suggested by König, the outer table of the frontal bone, with the intent and hope that something resembling the nasal bone might be secured. The so-called Italian method (named the Tagliacotian operation, after Tagliacozzi) consists in utilizing the skin of the arm, which is loosened according to a pattern previously made, leaving it connected only by a pedicle through which its blood supply is to be afforded. This flap is usually cut out and perfectly formed, then left loose upon the arm for about fifteen days until its viability has been thoroughly proved and its under surface is granulating. Then the edges of the defect in the nose are pared, as well as those of the flap, and the arm is brought into such position as to allow fitting the latter to the former, where it is held by stitches. The arm is held in proper position by cushions and by bandages of plaster of Paris until union has taken place, after which the pedicle is severed and the arm then released.

[Illustration: FIG. 444

“Saddle-nose” due to syphilitic destruction of bone. (Lexer.)]

Lesser deformities of the nose may be remedied or repaired in various ways. Angular deformities may be excised, while a sunken bridge may be raised, as Weir has suggested, through a bevelled incision at the junction of the nasal and maxillary bones, they being held in place by a transfixion pin. One of the most common and objectionable deformities is the so-called _saddle-nose_, which may be treated by Weir’s method, or which has afforded satisfactory results after the injection of paraffin. Roe, of Rochester, New York, has succeeded in remedying many of the more trifling nasal deformities by operation from within the nose, as, for instance, in case of _pug-nose_, where he dissects from within superfluous fat and connective tissue (Fig. 444).

HARE-LIP AND OPERATIONS UPON THE LIPS.

_Hare-lip_, or _coloboma of the upper lip_, is due to a failure in coalescence of the developing maxillary processes, which should unite early in fetal life to form the lip, alveolar process and roof of the mouth. This failure may involve but a trifling part of this line of normal junction or may be complete. Thus anywhere along it defects may be noted, such, for instance, as a little notch in the lip, a small opening in the hard or soft palate, or a bifid uvula. The defect in the lip alone is known as hare-lip because of its normal occurrence in the hare, and occurs on either side of the median line, absolute median fissure being extremely rare. It may occur alone or in combination with deeper fissures which involve the gum or the alveolar process alone or the entire palate. In extensive fissures of this character development is rarely symmetrical, and one side is usually not developed sufficiently to match the other. This makes operative treatment the more difficult. The more complete and extensive fissures are often complicated by excessive development of the intermaxillary bone, apparently from lack of pressure. This permits a projection of the septum, and especially of the central portion of the alveolar process, with a small part of the skin and connective tissue, which should have been blended into the lip proper. It represents the original intermaxillary bone with the portion which should have been developed downward from the nasal process of the midfrontal region. This gives a snout-like appearance to the face, and nearly always necessitates doing an operation for closure of the lip in two sittings. In Figs. 445 and 446 will be seen wide clefts with projecting intermaxillaries, while Fig. 447 illustrates a much more complete coloboma of the face, with complete bilateral fissures. Figs. 448 and 449 show the double form with philtrum or snout. Figs. 450 and 451 give the palatal conditions of irregularity and projection of the intermaxillary bone. (See Cleft Palate.)

[Illustration: FIG. 445

Incomplete hare-lip.]

[Illustration: FIG. 446

Complete fissure in double hare-lip.]

[Illustration: FIG. 447

Complete bilateral fissures (coloboma) of face. (Guersant.)]

All forms of hare-lip call for operation not alone for cosmetic purposes, but so that patients can nurse, drink, eat, and talk to better advantage. Obviously the earlier such operations are done, other things being equal, the better the results. When the cleft does not include the deeper tissues it may be closed within the first week or two of infancy. When the roof of the mouth is involved the surgeon is perplexed in deciding which is the better of two courses--to operate or to wait. Unquestionably by early closure of a fissured lip a gentle but constant influence is maintained to press the divided upper edges together, or at least to influence their more rapid growth toward each other. For this reason it would be desirable to operate early. On the other hand with a bad palatal defect it is a difficult thing to operate until, with the increasing age of the child, the mouth has attained a size which will permit the manipulations required for the purpose. Nevertheless, unless there be some special reason for delay it would appear wise, at least as a general rule, to operate early. (See Cleft Palate.)

[Illustration: FIG. 448

Double hare-lip with philtrum or snout.]

[Illustration: FIG. 449

Complete fissure, with labial defect and projecting intermaxillary. (Bruns.)]

[Illustration: FIG. 450

Illustrating the osseous (palatal) defect in complete fissures. (Bruns.)]

[Illustration: FIG. 451

Projecting intermaxillary bone. (Bruns.)]

The underlying principle of these operations is easily and briefly stated. The edges of the defect should be freshened and brought together by sutures. Extreme care should be taken that the vermilion border of the lip be maintained. A little particle of mucous membrane in the lip of an infant, dislocated to a level higher than that where it belongs, will appear later in life as a reddish patch upon the skin, which will prove quite a disfigurement. Simple fissure of the lip is easily managed by Nélaton’s procedure (Figs. 452 to 457). The deeper and more extensive the fissure the more plastic reconstruction is required.

[Illustration: FIG. 452

Malgaigne’s operation: the incision.]

[Illustration: FIG. 453

Malgaigne’s operation: the sutures in position; the lower sutures tied.]

[Illustration: FIG. 454

Nélaton’s operation: the incision.]

[Illustration: FIG. 455

Nélaton’s operation: the sutures.]

Incision, when necessary, may be extended around the angle of the nose on one side or both, and the lip should be dissected away from the bone sufficiently to make it movable. Operations by which a certain dovetailing of the little flaps is performed afford more security than a perfectly straight incision, but the resulting scar is rather more marked. The more perfectly the mucous membrane can be preserved upon the under side of the lip the better will be the result.

[Illustration: FIG. 456

The operation for double hare-lip.]

[Illustration: FIG. 457

Operation for double hare-lip: the sutures in position.]

Hare-lip pins have been abandoned. Sutures only are used, which may be of thread or horse-hair, catgut absorbing too rapidly. It is my custom to pass a retaining suture of stout silk through the cheek on either side, at a distance of one inch or so from the wound margin, to bring this forward in front of the alveolar process, and, by using a plate and shot on either end, to prevent tension upon the line of junction. This is very important, for children will fret and cry in a manner to tear out many a stitch not thus fortified. After operation young children should be snugly enclosed in a protective bandage around the chest, by which it shall be made impossible for them to get their hands to their mouths. It is vitally necessary to maintain absolute rest of the face and protection from any possible source of harm.

[Illustration: FIG. 458

FIG. 459

Line of incision, according to König.]

_Fissures of the lower lip_ are surgical curiosities. Should one be met it may be treated on the same general principles.

[Illustration: FIG. 460

Cheiloplastic operation on lower lip. (Tillmanns.)]

The other _cheiloplastic operations_ upon the lips are those made necessary by excisions of malignant growths, or by deforming cicatrices such as follow burns, syphilitic lesions, and the like.

[Illustration: FIG. 461

FIG. 462

Estlander’s cheiloplastic operation.]

Fig. 460 illustrates one method of filling a defect of the lower lip, while Figs. 461 and 462 indicate a method of bringing down a flap from the upper lip for the same purpose.

THE SALIVARY APPARATUS.

FOREIGN BODIES IN THE SALIVARY DUCTS.

Foreign bodies occasionally enter the salivary ducts, especially Stenson’s and Wharton’s, where they may set up an inflammation known as _sialoductilitis_. These may consist of bristles, fish-bones, and the like. Abscess, in consequence, may form in the gland or between it and the foreign body. Calculi also lodge in the ducts, where they remain as foreign bodies, producing sometimes a disproportionate amount of irritation.

FISTULAS OF THE SALIVARY DUCTS.

Fistulas of the salivary ducts involve Stenson’s duct. They open on the inside of the buccinator muscle, back of the orifice of the duct, which is opposite the second upper molar tooth. These fistulas of the parotid gland may be recognized by the passage of a probe from within the mouth. When they open externally they result nearly always from injury, and it is only the external forms which are troublesome. One may resort to the mildest measures first, and experiment with cauterization of the orifice or compression by occlusion. These measures will be ineffective if there be no opening upon the inside of the mouth, in which case one must be made by reëstablishing the original canal or forming a substitute. For this purpose a suture may be passed around the duct, back of the fistula, using a curved needle, and making it come out near the point of entrance. It should hold the duct in its loop. This suture may then be tightened and the distended duct punctured on the inside of the cheek. When once the flow of saliva is diverted to the mouth the edges of an external fistula may be pared and closed. In obstinate cases which have resisted all other methods it has been suggested to remove or destroy the gland which connects with the duct at fault. Even this is not an easy matter, but it can be done in the case of the parotid by careful dissection, with separation of the branches of the facial nerve and removal of the greater portion of the gland itself.

Congenital anomalies of the salivary glands are rare and of small import. Any one of them may be displaced, or either of them may connect with an accessory gland separated from it by an appreciable interval. Abnormal duct openings have also been noted.

INFLAMMATION OF THE SALIVARY GLANDS.

Inflammatory affections of the salivary glands give rise to _sialoadenitis_. Among these by all means the most common is _parotitis_ (_mumps_), which often occurs in epidemic form. It is an infectious and probably contagious disease, usually attacking the young, though no age is exempt. The period of incubation is about fourteen days. The condition begins with a stomatitis and with swelling of the affected parotid, with edema of the overlying tissues. It is accompanied by moderate fever. Swelling may be extensive and involve the entire neck region. The parotid on the other side becomes affected within a few days, although usually not to a similar extent. The other salivary glands occasionally participate. The febrile stage lasts for about a week, after which the swelling recedes and is gone within from two to four weeks. Occasionally the affected glands suppurate, in which case the condition may be very serious, since it may simulate Ludwig’s angina, or may be followed by sloughing and gangrene.

Save when abscess threatens the treatment should consist of warm antiseptic mouth-washes and the external application of an ichthyol-mercurial ointment or of Credé’s silver ointment. When suppuration threatens early incision should be made for the relief of tension and prevention of destruction.

A frequent and important _complication of parotitis is orchitis_, or swelling of the testicle. This is an unexplained feature of these cases, and occurs mainly in sexually mature individuals. It is the testis proper which suffers and not the epididymis. Suppuration here is rare. More or less atrophy is a remote consequence in many cases, estimated at about one-third. When both testicles are affected to a marked degree impotency may follow. Treatment of this orchitis consists in absolute rest in bed, with elevation of the parts affected, often with the application of an ice-bag. Painting the scrotal skin with guaiacol in small amount will often relieve pain. A similar complication occurs in the female, the _ovary_ being involved. Aside from this, other complications may occur in the breast, the vulvovaginal glands, the prostate, the heart, the eye, and the ear.

Apart from this somewhat specific affection the parotid and the other salivary glands may become involved in swelling and inflammation on account of surrounding local infections, or the presence of foreign bodies, stones in the ducts, etc. Metastatic abscesses, especially in the parotid, are not uncommon. Considering the open pathways offered it is surprising that these glands are not oftener involved in septic conditions of the mouth.

MIKULICZ’S DISEASE.

Mikulicz has described a not very infrequent simultaneous affection of two or more of the salivary glands, occurring in middle age, characterized by uniform swelling which may involve even the palatine, labial, and buccal glands. It is spoken of in German literature as _Mikulicz’s disease_. The swelling progresses slowly, so that the glands reach a varying size in the course of years. Thus the parotid glands may attain the size of the fist, and other glands a corresponding increase. Sometimes the adjoining lymphatics are also involved. The enlargements are not tender, but may interfere with movements of the tongue and jaw. These tumors have been known to recede after an intercurrent acute disease. Nothing is as yet known of the cause or nature of the affection. In its treatment arsenic and potassium iodide have given perhaps the most favorable results.

The salivary glands, especially the parotid, are as likely to be involved in the manifestations of tuberculosis, actinomycosis, and syphilis as are the other structures of the body. Lesions of these various natures will be appreciated without further description.

TUMORS OF THE SALIVARY GLANDS.

Tumors of the salivary glands are not uncommon. The parotid is more frequently affected than either of the others. These tumors may be of cystic character, either large from obstruction of the excretory duct, or small and numerous. Almost all the tumors described in