[From the Charleston Medical Journal and Review, April, 1875.] 
Art. V.— Cancroid or Epithelioma of the Lower-Lip ■ Modified 
Operation for its Removal / Cure. By Middletok Michel, 
M. D., Professor of Physiology and Histology in the Medical 
College of the State of South Carolina, Charleston. 
Mr. , of Massachusetts, residing temporarily in Beaufort, 
S. C., aged about fifty years, of healthy constitution, has suffered 
for two years from a cancroid disease of the lower-lip. The 
tumor, about the size of a walnut, extended from near the right 
labial commissure to a little beyond the mesial line of the face. 
The growth was incrusted by a scab, but did not reach the rau- 
cous border of the lip, nor did it dip deep into the subjacent tissues, 
as it had not involved the mucous layer beneath. There was no 
pain, though he was ranch annoyed by its size and situation. It 
first made its appearance as a warty excrescence about two years 
ago, and grew very slowly. Being in the habit of teasing it oc- 
casionally with his fingers, he at last accidentally pulled it en- 
tirely off some time in the month of October last, which appears 
to have aggravated it, since it then grew rapidly to its present 
dimensions within three months. Dr. H. M. Stuart, his family 
physician, finding that local treatment, consisting of various un- 
guenta, including several applications of nitrate of silver, and 
constitutional remedies, had no effect, advised the removal of the 
tumor with the knife, and brought him, in person, to me on the 
sth January. Mr. ascribed the early manifestation of 
this cancroid to his immoderate use of tobacco, as he generalH, 
though not always carried the pipe or segar upon the right side 
of the mouth, and therefore he discontinued smoking for more 
than a year. There seems to be no hereditary claim to a cancer- 
ous diathesis, and his health is perfect. Wishing to combine 
cauterization with incision, should the latter become absolutely 
necessary, and having sometimes witnessed the marvellous effects 2 
Michel on Cancroid or Epithelioma of the Lower-Lip. 
of the application of the sulphuric acid and saffron paste, I sug- 
gested its trial before resorting to the knife, prescribing also 
forty minims of Neligan’s ioduretted solution of iodide of potas- 
sium and arsenic, to be gradually increased to eighty drops, 
thrice daily. This paste was at once applied, and formed as 
usual a hard investment, and he returned to Beaufort. When 
the button fell off, Dr, Stuart reapplied the same to a much more 
healthy looking surface, as he informed me by letter, but in the 
course of a few weeks the disease seemed aggravated, and Mr. 
returned to the city to have it excised. The black scab 
which adhered with tenacity to the part, was now loosened by a 
poultice, and upon detaching it, as a point of great interest to 
me pathologically, I recognized for the first time, and with the 
naked eye, elongated, filiform, acuminated projections, liberating 
themselves from the growth as I pulled it slowly off, resembling 
so many short pegs attached to a shoe-sole, which proved to be 
the diffused and hypertrophiedpapillra of the derm, of which I 
easily counted from eighteen to twenty, occupying the denuded 
surface, and zone of the primary tumor. This was clearly the 
papillary variety of cancroid of the skin, regarded by some as 
not so benign as the purely epidermic and perhaps more likely to 
return. The caustic had completely destroyed the epidermic, and 
so pulpified the papillary layer that on pressure with a delicate 
sponge probang their reduction into a pasty detritus of the color 
and consistency of very thick pus was readily effected; as there 
was an obvious extension of the surface however, I determined 
to remove the whole of the disease by incision. 
On Thursday, February 11th, placing the patient under the 
influence of sulphuric Ether, the following operation was per- 
formed: 
Making a semi-circular incision two lines from the diseased 
part, and entirely circumscribing it, the whole growth was dis- 
sected away down to the mucous layer, this being preserved in- 
tact, then paring away the remains of all suspicious tissue with 
the scissors, and saving thereby every available portion of integ- 
ument which the usual V incision could not have done, Not- 
withstanding the wound left by the ablation of this tumor, it 
possessed that continuity of surface and tissue which’ great-, 
ly facilitated, or perhaps rendered possible, that approxima- 
tion of its edges, which, with some tension of the parts, were 
brought carefully together and held united by harelip needles, 
secured by a figure of eight suture. Two delicate silk sutures 
were then added, one at the mucous border of lip, the other at 
the lower extremity of the wound, which now presented a per- 
fectly vertical line corresponding to the raphe of the lip. The 
only dressings were compresses dipped frequently into cold wa- 
ter, during five days, when, after scarcely any suppuration, the 
wound was almost entirely healed. Though the mouth is drawn 
smaller, there exists not the slightest deformity. Michel on Cancroid or Epithelioma of the Lower-Lip. 
3 
I publish this simple case with the sole object of calling atten- 
tion to the operative procedure, the chief feature of which con- 
sists in the preservation of the entire mucous membrane, which, 
with more or less available and useful integument, is completely 
sacrificed for the smallest tumors in the classic Y incision inva- 
riably practised. In commenting on this preservation of the 
mucous layer, I wish to revive, if possible, a modification of the 
usual operation, so wholly neglected that perhaps few if any wri- 
ters on surgery refer to it. Though practised more than half a 
century ago, no one, if wTe except Mr. Syme, seems to have con- 
sidered it, and even his endorsement, completely substantiating 
its results has not evidently met with any kind of notice even in 
the most elaborate works before us. Nelat on and Malgaigne, 
with their national clearness, minuteness of detail, and exhaus- 
tiveness of the subjects with which they deal, make not the 
slightest allusion to a result, which, though an isolated one, was 
verified at the time by such men as Bedard, Breschet, Cloquet, 
and Ribes. It is now more than fifty years ago since Richerand 
removed the entire lower-lip from angle to angle, leaving inten- 
tionally its entire mucous membrane, and producing so hideous 
a wound, that had nature not operated most skilfully in the pro- 
duction of a lip, the patient could never afterwards have been 
able to retain her saliva ; yet this mutilation in a fortnight was 
scarcely perceptible. He daily watched the ■ progressive stages 
of repair as the new skin or tissue marched steadily onwards to 
join the labial border of the retained mucous membrane, until a 
perfect lip was reconstructed from its gingival to its buccal limits 
Yet it is strange that a modification so simple compared to the 
complicated methods of plastic surgery should so long have lain 
in comparative oblivion that it has never since been practised 
but by M. Syme. 
When a basement layer of organized tissue exists, we need 
not look with surprise at an extensive reproduction of territo- 
rial tissue—if I may use an expression by which I mean to imply 
tissue of the same nature as that of the spot itself—for I have 
seen, as others have, structure of considerable import reformed 
after extensive disorganization and actual removal, as where the 
entire scrotum was reproduced. 
In advocating then this most useful advance in conservative 
surgery, made practicable in the simple retention and employ- 
ment of an entire mucous layer, I must be understood as restrict- 
ing this method absolutely to cancroid disease or epithelioma, 
as Hannover termed it, which is different from cancer. With no 
desire of entering into the pathogenesis of cancer, or discussing 
the existence or non-existence of a specific polymorphous ele- 
ment as always characteristic of the disease, yet the bearing of 
the question upon the real nature of epithelioma, and the dis- 
crimination which must be made between a benign growth and 4 
Michel on Cancroid or Epithelioma of the Lower-Lip. 
a malignant cancer before selecting this operation, compels me 
to refer, however briefly, to the subject. 
Where a difference of opinion exists among pathologists of 
equal repute, it is but proper to call in the verdict of practical 
surgery, and I am willing to subscribe to the universal testimony 
that cancroid appears to be a local disease, which, once removed, 
seldom reappears, especially in that variety of the affection which 
most frequently invades or occupies the lower-lip. I have 
always believed that' epidermic cancroid is a benign disease; 
perhaps a homeomorphous affection, which introduces no new 
element as a substitute for the normal structure, and not diffus- 
ing its influence beyond its oivn immediate zone, by propagating 
itself like cancer into adjacent parts ; a strictly local, not consti- 
tutional affection, which seldom therefore returns, however far it 
may itself have extended. But even assuming cancroid to be a 
primary stage of true cancer, if, as experience teaches, its sta- 
tionary cells sometimes live out their lives in one locality, with- 
out traveling to distant parts and there-proliferating ; undergo- 
ing no metamorphic retrogression, though extending their do- 
main in the region they inhabit; and in their sway over the 
parts involved, impeding function, destroying comfort, and 
depressing the mind of the patient; I will call such a cancer 
non-malignant, benign ; and I say remove it, for it will not 
perhaps return. I would even restrict the operation again to the 
two varieties of the disease known as epithelial and papillary 
cancroid, since in the third variety—the dermo-epidemic cancroid— 
a transport of cancroid even to the glands of its own special 
region may and does sometimes occur, though even here this is 
obviously different from cancerous infiltration, which, without 
limit, travels through the vascular channels into remote parts of 
the body. 
I would not have it understood that I reject altogether the 
celsian Y incision, for in limited growths or small tumors it is 
the obvious duty of the surgeon to give his patient a clean cut, 
when he simply thereby converts the wound into an artificial 
hare-lip of easy adjustment; but I advocate this mode of operat- 
ing as well calculated to allay the embarrassment and apprehen- 
sion of those who, in presence of an epithelioma invading half, 
or it may be the whole of the lip, are necessarily led to contem- 
plate the irremediable gap, which nothing but some cheiloplastic 
operation, as bold as the formidable procedure of a Dieffenbach 
through cheek and chin involving facial artery and nerve and 
possibly parotid duct, could fill ; or some modification of a like 
kind with its attendant sequelae, erysipelas—an alarming source 
of failure in plastic surgery; erythematous inflammation, often- 
times troublesome and painful; not to speak of a yet more fre- 
quent source of disappointment, after-contractions. 
Too much importance cannot be given to the retention of the Michel on Cancroid or Epithelioma of the Eoicer-Lip. 
5 
entire mucous membrane of the lip, since a basis is furnished under 
all circumstances for an out-growth of granulations from a perfect- 
ly healthy layer of subjacent tissue in a vast majority of cases, even 
of the third and worst variety of the disease. Should a case pre- 
sent itself then in which the entire lip was compromitted by an 
Epithelioma, I should carefully remove with the scalpel all of 
the disease, leaving the entire mucous layer to granulate and 
perform an restoration of the organ, and this I should 
do with the utmost confidence in the reparative powers of so 
highly vascular a region as the face, for in gun-shot injuries in 
this part, I have been strikingly impressed with the wonderful 
processes of healing, when the slightest substratum of organized 
tissue remained; and equally surprised at the very little sul«e- j 
quent deformity which resulted, even after the severest muting 
tions from fire-arms of every description. Nor need we be ap- 
prehensive of the two ready transport of cancroid elements to the 
incised wound; a reinoculation of epithelial globes as they have 
been termed—those ovoid or round bodies composed of concentric 
layers of epidermic scales—since in the worst forms of epithelioma 
these may be destroyed by cauterization. Where cancerous in- 
fection is seriously to be dreaded in the supposed escape of germs 
liberated accidentally from the mass which is being excised, have 
we no escharotic which, applied to the bleeding wound, may im- 
mediately destroy them, without exposure to the fatal result, that 
befell M. Roux’s young patient from the arsenical preparation of 
Rousselot, which no one will again apply to a fresh wound ? I 
think we have; not from my own experience, but from the testi- 
mony of those who extol a solution of chloride of zinc. Now, 
this solution which may be used as strong as twenty, thirty and 
forty grains to the ounce, has been applied to extensive and thin 
flaps, in such operations as the amputations of Syme and Mac- 
kensie, with encouraging results. Swabbing the surface, over 
any thickened tissue that remains, even to within a short dis- 
tance of the mucous structure itself must exercise an antiseptic 
effect, since we are told that for two or three days the pus, which 
flows from such a wound, has not the slightest fetor, and that the 
destructive consequences to be expected from so potent an escha- 
rotic never really occur. As for the pain attendant upon this 
application, which at most lasts but two hours, under anaesthesia 
and hypodermic injections, this may be generally controlled. 
It may be thought by those familiar with the history of plastic 
surgery that the principle I am advocating has long been recog- 
nized, since Von Ammon refers to the importance of the preser- 
vation of the mucous membrane; and it will also be affirmed that 
Delpech once wrote: “Give me mucous membrane to cover the bor- 
der of my new lip, and there is not a defect which I will not under- 
take to remedy.” Imitating his confrere M. Serre also enforced the 
same course in accommodating the transplanted flap to the ancient 6 
Michel on Cancroid or Epithelioma of the Lower-Lip. 
mucous membrane, except when this Avas involved in the disease. 
But it must be noticed that these suggestions from Ammon, Del- 
pecb, and Serre are offered as supplemental steps in cbeiloplastic 
operations, for more perfectly accommodating the migratory flap 
to its new position, and only with the view of preventing the sub- 
sequent inversion of the flap at its labial border, a frequent result 
of the contraction of the tissue; my object is to offer a self- 
restoring membranous surface, Avhich auto-pl as tically repairs a 
breach, which only a formidable operation is universally called 
into requisition to restore, and I therefore have laid such stress 
upon this point in the hope that should the future repeat the results 
herein narrated, this blastodermic method, as I would terra it, 
may, in very many instances dispense with the difficult though 
ingenious methods of plastic surgery.