Reprint from St. Louis Medical and Surgical Journal, November, 1890. A Case of Rhinophyma-Operation. By A. H. Ohmann- Dumesnil, Professor of Dermatology and Syphilology in the St. Louis College of Physicians and Surgeons. Acne rosacea is perhaps as common an affection of the skin as is observed by any one not devoting any especial attention to dermatology. Cases of " rum nose " may be con- stantly met with in our streets and, whether due to alcoholic excesses or not, they are the cause of more or less distress to those afflicted in this manner. Of the disease itself I do not purpose speaking except in so far as the so-called third or hypertrophic stage is concerned. In this condition we have several degrees of deformity differing more in regard to the size attained by the nasal organ than in any other respect. The condition which is known as rhinophyma is essentially a hypertrophy in which there exists a tendency to the forma- tion of dense fibrous tissue attended with a gradual increase in the size of the affected organ. As cases become older, one of two conditions supervenes. A sudden standstill takes place in the process, which is always comparatively slow; or, it continues until we are confronted with the condition known as pendulous nose, a deformity which is best appreciated by seeing it. The tissues become much thickened, the ducts of the sebaceous glands are enlarged, their orifices gape, and lobules are formed, the entire integument being thickened and rough in appearance, its surface assuming a greasy, shin- ing appearance. While not rare, by any means, this condition is not com- mon, and it is seldom that curative measures are applied for in order to ameliorate the condition or for cosmetic purposes. This is probably due to the fact that it occurs most often in men who are advanced in life and in whom the idea has formed itself that it matters but little whether their personal appear- ance is pleasing or the reverse. In addition, being most often caused by indulgence in alcoholics, they are deterred from seeking medical advice by the fear that their tippling might be interfered with or prohibited. 2 The case which I am about to describe is one which pos- sesses several interesting features, and it is for this reason that I have deemed it worthy of being placed upon record, together with a brief description of the microscopic appear- ances presented by the excised portions. The favorable ter- mination of the operative measures employed, both from a cosmetic point of view are also not uninteresting, these being always important points to be considered by those anxious to secure practical results rather than theoretical points. The symptoms of the case are also of some interest, as well as the direct effects of the disease in this case, a condition to which attention has not been heretofore called, so far as I know. With these few introductory remarks I will describe the case for an opportunity of seeing which I am indebted to Dr. H. Wichman, of this city, who also had the photograph taken from which the accompanying engraving was made. Case.-Mr. X , about 72 years of age is of a rather robust constitution and has always enjoyed good health. A saloon-keeper by occupation, he has been accustomed to in- dulgence in alcoholics, and in consequence of this developed an acne rosacea. When the trouble first appeared he cannot remember, but he does recall to his mind that he first noticed an enlargement of the nose in 1884. This progressed steadi- ly up to the time he sought relief and, latterly, the enlarge- ment seemed to progress rather rapidly. He paid but little attention to the appearance which he presented, and would probably not have sought relief had it not been for the incon- venience occasioned, a condition which, as I have already stated, I do not recall having seen mentioned heretofore. The hypertrophy became so marked and there was so much tissue developed that the weight of the superincumbent masses pressed upon his nostrils. This pressure existed to such an extent that he could no longer breathe comfortably. The weight of the tumor was such that it produced stenosis of the nostrils and he had to breathe through his mouth, a condition which, although but uncomfortable at first, finally became intolerable. The condition which the patient presented when he ap- plied for treatment was as follows: He appeared to be in good health, inclined to be stout. The hair was gray and the complexion florid. His nose was enormously hypertrophied. 3 The deformity consisted of three masses (see Fig. 1) or lobes, one central and two lateral, attached at their bases by rather large pedicles. The surface of the integument was irregular, the openings of the ducts patulous and the mass felt hard to the touch. Each lateral mass was pear-shaped,the central one Fig. 1. Rhinophyma. having a resemblance to an inverted pyramid. Taken to- gether this hypertrophied portion would make a large hand- ful. In a case of this kind it was obvious that there was but one course to pursue-remove the entire mass by the knife. No other treatment could offer any hope of relief and accordingly 4 this was done on June 10, 1890 by Dr. A. C. Bernays who had been called upon to perform the operation which was about as follows : The lobes of the tumor mass were removed leaving a small flap of the integument of each in order to cover the denuded surface. This flap in each case was derived from the lower part and laid up so as to bring the line of stitches at about that portion of the nose which would correspond to the sulcus of each ala. In the case of the middle lobe, of course, the line of sutures was directly across the nose. The dissec- tion of the skin flaps was carefully done so as to have as thin an integument as was consistent with the nutrition of the parts. Healing occurred per pr imam, the dressing in this case having been iodoform collodion, The final result was a good one with the exception of a very slight deformity which could hardly be avoided and which would probably attract but little or no attention. This consisted of a slight tilting up of the openings of the nostrils due, no doubt, to the cicatricial con- traction at the site of the sutures. As I have stated, it amounted to but little and merely pointed to the necessity of allowing for contraction both of the integument as well as of the scar in such cases. At best, however, it is a difficult mat- ter to estimate exactly the amount of skin required in plastic operations of this character and in such cases as the one before us a little too much economy is far preferable to generosity, as any redundant tissue might be prone to take on the hyper- trophic process rapidly and soon reproduce, in part at least, the original trouble. Ocular examination of the excised portion shows that the structure of the growth is distinctly fibrous, the density being marked. The skin covering this hypertrophied part is thin,t being more so in the side lobes than in the central one. The openings of the ducts of the sebaceous glands are large and patulous, more especially in the central lobe. In one side lobe there exists what appears to be a large retention cyst, nearly a half inch in diameter and a number of smaller ones, these latter existing also in the other side lobe, although they cannot be made out in the tissues of the central lobe. The cavity of the cyst is filled with a mass of fat that is more or less cheesy in appearance, and the smaller cysts show the same feature present in them. Here and there an enlarged blood-vessel can be plainly seen in cross section and some 5 portions of the structure seem to indicate the presence of de- generative processes. The microscopic anatomy of this trouble has been studied by several competent observers from a few of whom I wish to make some quotations. The descriptions seem to differ somewhat in detail and this discrepancy is probably due to the fact that each one was limited to the appearance pre- sented by but few specimens. In the case I have detailed above the different appearances presented agreed pretty well with the various descriptions given, so that it is pretty safe to conclude that the microscopic anatomy is probably of a very similar character, if not the same in every case of rhino- phyma. Hans Hebra who wrote an elaborate paper1 on this disease including its microscopic anatomy states, in reference to the latter that the sebaceous glands are exceedingly numerous and large, and that they form quite a prominent element in the pathological condition which is present. He believes that this hypertrophic condition is secondary to the connect- ive tissue hypertrophy, which by its development secludes and cuts off portions of sebaceous glands, which then go on secreting and produce a retention of sebum which in turn acts as an irritant, stimulating further hypertrophy. Biesiadecki2 also found distension and hydrtrophy of the sebacenous gland, together with the enlargement and new formation of bloodvessels, both in the superficial layer and in the branches rising from the corium. Piffard3 examined a case operated on by C. Wagner, and found that the horny layer of the skin was scanty, but the rete mucosum thick, with well formed cells. The papillae were enlarged in length and breath and contained round and fusi- form cells. The sebacenous glands were normal, others were undergoing degenerative changes. The corium was greatly thickened and presented the appearance of a formed tissue. Bulkley * in describing a case, states that the tumor is composed of closely woven connective tissue fibres, embracing relatively large blood-vessels ; the rete and epidermis are un- changed, and in this specimen there appears but a single seb- 1. Vierteljahresschrift fuer Dermatologie und Syphilis, Heft 4,1881. 2 Pathologie and Therapie der Hautkrankheiten, von M. Kaposi, 1883. 3 Archives of Clinical Surgery, Vol. I. p. 21. 4 Acne and its Treatment. 1885. 6 aceous gland, not greatly enlarged. Blood-vessels consist of arteries with hypertrophied coats and dilated veins. There is more or less small cell infiltration also seen in the tissue, together with many embryonic cells. In the figure which is given (Fig. 26, page 216, by Elliot), the papillae have all dis- appeared, numerous enlarged blood-vessels are shown, the rete is distinct and the stratum corneum somewhat thinned. No sebaceous glands appear and a small-cell infiltration is shown here and there throughout the fibrous tissue of the tumor, this tissue appearing to be one with the corium. In the case, which I have described above, I made a num- ber of sections of the different parts of the tumor, and found conditions which agree with these several descriptions of different authors, a fact which has led me to conclude that these examinations had been limited to but small portions in each case. This would also seem to indicate that in different portions of a tumor of this nature, different conditions are present so far as as details are concerned, the general process being the same in all. In the specimens which I prepared and examined, 1 found the horny layer of the epidermis slightly thinner than the normal, but not markedly so. The rete was well marked, each cell showing distinctly, and its nucleus well defined (Fig. 2). As a rule, the inter-papillary projections had disappeared, showing themselves in but a few specimens derived near the normal skin. The corium could not be differentiated, but seemed to merge insensibly into the fibrous tissue of which the general mass of the tumor seemed to be composed. Throughout this fibrous formation could be distinguished, scattered here and there, small round cells as described in Bulkley's specimens. As a general rule, the sebaceous glands were rather abundant, and somewhat enlarged. Their interior seemed to be filled with sebum, and their ducts free to permit its escape. In some portions of the tumor, these glands were so abundant as to touch each other throughout the specimens taken. In other portions, they were more sparsely distributed. Here and there could be distinguished retention cysts in which the specific characteristics of the sebaceous glands had disappeared, the walls being, for the most part, of a fibrous nature. Blood-vessels were abundant and large, suggesting not only 7 a hypertrophic process, but a new formation. Their walls were thickened, and they appeared throughout the fibrous structure. A feature which I have not noticed in the reports of other microscopic examinations of rhinophyma and which I ob- served in my specimens was the presence of disseminated masses of fat (Fig. 2). These masses, while not large, sug- gest very strongly the fat of the subcutaneous tissue, and would lead to the conclusion that this tissue had become more or less hypertrophic in so far as the generation of an excessive amount of fibrous tissue was concerned, this pro- Fig. 2. Section of Rhinophyma. ducing a certain degree of compression to the extent of mak- ing it continuous with and indistinguishable from the general fibrous structure of the tumor. It could not be attributed to fatty degeneration as the distribution would be entirely dif- ferent, and yet the distance from the lower level of the tumor that these masses of fat are found at, militate somewhat against their derivation from the subcutaneous fat, unless we are willing to admit them as portions of Warren's column© adipos© which have somehow become separated during the process of hypertrophy. I have merely briefly outlined the subject and intend giv ing further study to some interesting problems presented by it. The entire case is one which is interesting and this is the only apology I can present for the space I have consumed in devoting a paper to it. 5 South Broadway.