body we met at his home and buried him, after Drs. Giffin and Allen had briefly spoken in eulogy. It was then truly said: "Dr. Coman was a noble, true, tenderhearted, sympathizing, faithful servant of the sick." That was and is eulogy enough for any man. "Requiescat in pace." Many incidents might be added to this. fragmentary narration of early days and the pioneers of those days, but I have already, I fear, wearied you by the length of my paper, and will now close, thanking you for your indulgence. CANCER OF LIP AND FACE.* By W. W. GRANT, Denver, Colo. I desire to report two cases of cancer of the face, both originating as usual, in the lower lip. Case No. I was reported in a paper read before the Surgical Section of the A. M. A. at its recent Portland meeting. Case 1. Fig. 2. operation. The gums and alveoli did not show involvement at first operation, but there was recurrence in June, involving the gums of left half of mouth, and a circular ulcer of lower lip, adjacent and near the left corner of the mouth. I operated on him June 30th, for the relief of the condition. A straight downward incision was made from the left corner of the mouth, and the tissues separated from the maxilla in front; the ulcer was excised and most of the front teeth extracted, including the left biscuspid. With bone cutters the alveoli and upper half of maxilla was removed. The border of the lip was not involved, consequently was not excised. The lip was stitched to its place at the angle of the mouth, and to fill the gap due to removal of the lip ulcer, two straight parallel incisions were made downward from the lower border of the gap, and a rectangular flap dissected and this, I operated as follows, on September the upper lip from upper part of the vesti13th: A straight transverse incision was made in the depression between lip and apex of chin, from the midline of the mouth far into the left cheek. The lip above the incision was dissected from the maxilla in front, and some distance beyond the left angle of the mouth. Another incision was now made, beginning in the previous incision, at a point below angle of mouth, diverging immediately but gradually from and below the other. These incisions extended as far back as the angle of the maxilla. The tongue shaped flap was dissected and pulled forward into the space left by lifting the lip and corner of the mouth upwards, and stitched to the lip and bule, the lip being pulled downwards in the meantime, to prevent too much sagging. The sutures were tied over bits of sterile gauze. The result is excellent, as shown in the photographs taken before and after the removal of the stitches. (Fig. 4.) The dribbling of saliva, previously very annoying, ceased at once, and he talks and eats with no difficulty, and feels perfectly well. Case No. 2. B., age 60. Carcinoma. beginning in the lower lip two and onehalf years ago. For six months prior to August 8th, his lip was treated, three times a week, with X-ray. When the treatment was commenced, the disease, he says, was confined to the lower lip. lip and ligated vessels, on the proximal The result of treatment was a rapid side. This process was continued step by extension of the disease and slough- step around the cheek and lower side of ing of the lip. At the time of op- face until facial artery was cut and ligated, eration, the disease had extended to the using compression forceps at certain proxouter third of the upper lip on each side, imal points, and ligating the tissues on the and had invaded the cheeks extensively, diseased side and cutting between. After and extended further on the inside than securing the facial artery on one side, the on the out. The anterior part of chin to dissection was stopped for the moment at tip was ulcerated. The photograph (Fig. 1) shows quite satisfactorily the outward appearance of the disease. The submaxThe submaxillary glandular involvement was extensive. The condition was so bad that surgery did not hold out much hope of successful intervention, but he wanted the operation done, and on August 8th, assisted by Dr. R. G. Morrison and Dr. Kenney, anæsthetist, I performed the operation. On account of the extensive involvement and destruction of tissue, no known operation could possibly meet the indications, so I proceeded in the following manner: Taking and completing one side at a time, I first ligated the upper lip on the outer or diseased side; then divided the Case 2. Fig. 2. this point, and the same procedure gone through on the opposite side. When both facials were ligated, the diseased mass was then quickly removed with insignificant hemorrhage. The incisors and cuspids were now extracted, and with bone pliers, the upper half of the maxilla was cut away. The skin beneath maxilla and anterior part of neck, was turned down to the level of the inferior border of the thyroid cartilage, and the glands now removed, including the periosteal attachment to the left submaxillary gland. The remnant of the cheek was dissected from the superior maxilla, the lower flap now turned up, and the two stitched together, as far as it was possible to do it with the minimum amount of tissue left. A con and pulled it up over the symphisis of the maxilla, and stitched it to the side flaps. The objection to such a flap is two-fold. First, it has no mucous covering either for the posterior surface, or for the border of the lip. Secondly, this flap is always followed by such contraction as to leave the lip short, with consequent disfigurement and escape of saliva-both very important objections. To supply the necessary mucous membrane, I employed a device that can only be used when the front teeth and the alveolar processes are removed. After stitching the anterior and side flaps, I drained the floor of the mouth with a small rubber "T" drainage tube, making a buttonhole slit in the submental space for the purpose. The divided mucous membrane beneath the tongue was now stitched to the middle of the posterior surface of the flap intended for the lower lip. This procedure covered in both the upper surface of the maxilla and the drainage tube. The latter was withdrawn at the end of a week, through the submental incision. The effort was attended with gratifying success, as there is a movable, free border, with one-half inch of posterior surface, well covered with mucous membrane. The tension of the flap was necessarily great, and the tendency to downward dislocation, inevitable. To relieve this and to repair the gap at the corners of the mouth, I performed the following operation, on September 25th, ten days ago. The condition is illustrated by photograph (Fig. 2.) The concave border of the upper lip resulting from first operation was denuded, and a straight backward incision was made from its outer and upper side, through the cheek, nearly to the ear. The incision included muscles, but not mucous membrane, as it was too deficient to permit it. A similar incision was then made obliquely downward from the angle of the abnormal mouth. The whole flap was now pulled forward and stitched to the upper lip, and again at the inferior angle to the denuded lower flap, for a short distance; also, a few stitches in the cheek, from which it has just been separated, in order to permit the central flap to slide forward. To relieve the downward traction on anterior flap and lower lip, I made a transverse incision, about three inches long, through skin and fascia, beneath the maxilla, on a line with the upper border of the thyroid cartilage. Pulling the chin upwards, made a gap an inch wide, which was immediately filled by making parallel incisions down the neck from the right angle of the gap-a flap dissected and transferred to this space. The stump of the flap was not divided, giving a better blood supply. The space from which flap was taken, was immediately stitched without tension or difficulty. Union by first intention throughout entire operation was secured. Fig. 3 illustrates the condition at present, on right side and neck. The left side will still require a small tongueshaped flap to elevate the angle of the mouth. The circulation of the lip flap is greatly improved since the operation. It looks well and quite natural. This completes—with the exception noted—a most difficult operation, performed under adverse and very discouraging conditions, with a better immediate result than seemed probable. He has gained 12 pounds since first operation, seven weeks ago, and his color and general condition are good. These cases are not reported as cures. In all bad, neglected cases, in which radical surgical procedures have been delayed until the case seems hopeless, permanent good results can hardly be expected. Yet these curative efforts are fully just ified, for life in every case has been prolonged, the condition has been vastly improved, some probably cured, and with all a new lease of clean, comfortable existence. It is demonstrated what can be done by very elaborate chiloplastic efforts, and with how much confidence we can approach the solution of the problem, when given a reasonably early opportunity. Discussion. Dr. Blaine: Dr. Grant has informed you of the treatment of the second case, received prior to his advent into the case. He neglected to state the treatment the first case had received. This case was sent to me from Chicago last March, with a letter from Dr. Hyde. The patient had been exposed to the influence of the X-rays practically all of last winter. His daughter lived in Denver, and she thought it would be a good scheme to bring him out here. She asked me if I would treat him, and I said I would if it was in my line. But when she described, as nearly as she could, the conditions, I told her she had better have him see a good man before any time was wasted, and I sent him a letter of introduction to Dr. Hyde of Chicago. As soon as Dr. Hyde saw him he saw he wanted to come to Colorado, and he wrote me a letter and sent him on the next train, with apologies for sending such a case. When the case came to my office the next day I saw it was not in my line. But I want to say right here, surgeons to the contrary notwithstanding, there is a dermatological stage to every outside epithelioma. Those I always treat, of course, and treat them successfully, too. I have been compelled to sit in the Denver County Medical Society time and again and hear surgeons refer to quack paste. There never was any such thing as a quack paste. The component parts of a caustic application are all taken from the pharmacopeia and their formulae are known, and anyone who wishes to can study them. As I said in my remarks the other day, the things that are used for every pathologic condition become fads, and that is what I said in regard to the X-ray the other day, but I have not heard any of my surgical friends speak of using quack X-ray. The X-ray, as I have said, is a scientific proposition, and has its use. This case, when it came to me, was entirely beyond my realm, and I worked for a week trying to persuade them to allow me to call in my friend, Dr. Grant. I want to congratulate Dr. Grant on the apparent good result of his operation. The last time I saw the old gentleman he was looking fine. Since then the doctor informs me he has had another operation performed; but if there is any hope for affording the old gentleman any relief, I am sure Dr. Grant is affording that relief. Discussion Closed. Dr. Grant: I wish to allude to the fact that it is not my first report on this case. I stated that this man had been treated with some benefit by paste application in the early stages. It did not cure him. He was then treated three or four months in Chicago with the X-ray, which failed to correct his condition. I have expressed the opinion that the X-ray in these cases was only applicable in the very superficial ulcerations. While quite uniformly curative of the tubercular ulcer, or lupus, it fails in epithelioma when there is much hardening of the tissues or glandular involvement. Dr. |