IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I 1.25 Il l 1.8 U ill 1.6 % p*. >> > ^' /A ^ 'V '/ Photographic Sciences CorpoiBtion 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 '% CIHM/ICMH Microfiche Series. CIHM/ICMH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques O^ Technical and Bibliographic Notea/Notas tachniquoa at bibiiographiquas Tha Instituta has attamptad to obtain tha bast original copy availabia for filming. 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Lorsque le document est trop grsnd pour Atrc reproduit en un soul ciichA, 11 est film* A partir de Tangle aupAriaur gauche, de gauche h droits, et de hfiut en bee, an prenant le nombre d'Imegee nAceasaire. Las dlagrammes suivants illustrant la m^thode. 1 2 3 1 2 3 4 5 6 S/fCpffft-r/^ f, J, Reprint from Anna'.;; of Surgery, Nov., 1888. A CASE OF EXCISION OF THE TONGUE, FOL- LOWED BY DEATH FROM ACUTE MILIARY TUBERCULOSIS.' By FRANCIS J. SHEPHERD, M.D., M.R.C.S. OF MONTREAL. PROFESSOR OF ANATOMY IN M'GII.I- UNIVERSITY; SURGEON TO THE MONTREAL GENERAL HOSPITAL. A STRONG healthy, looking Irishman, A. W., set. 64, entered the Sr\. Montreal Hospital May 19, 1888, suffering from an ulcer of the tongue. Last September, first noticed a small hard nodule on the left side of the tongue, about one inch from the tip and opposite a sharp decayed tooth. The growth annoyed him greatly, and he con- sulted a medical man who cauterized it. An ulcer soon formed which increased slowly. Last March another lump appeared nearer the tip of the tongue which also ulcerated. The ulcer was pamful from the first. Patient has never been ill in his life, never had any cough. Has been a moderate smoker. Family history negative. His condition on entering hospital was as follows: "Small, spare,active man of considerable vigor, is 64 years of age but looks younger. On the left side of the tongue, commencing .vbout half an inch from the tip, is an irregular fissured ulcer divided into two parts by a nodule of induration ; the cages of the ulcer are ragged, and the base sloughyj the base is in- durated, and the ulcer is surrounded by a mass of induration the size of an almond. There is considerable pain, and the patient is unable to masticate his food on the affected side ; there is not much salivation and no fetor, and but little interference with articulation. On examin- ing the submaxillary region some small hard glands are felt, which are quite movable. Examination of the various organs revealed no evi- dence of disease. Temperature, pulse, and respirations normal." A portion of the growth was snipped off and examined microscopic- ally, but nothipg but epithelial elements found. On consultation with my colleagues taking into consideration the history of the case, the age of the patient, the appearance of the ulcer with its indurated base and the involvment of the sub-maxillary lym- 'Read before the Montreal Medico-Chirurgical Society, June 22, 1888. FRANCIS J. SHEPHERD. phatic glands, it was thought that the case was one of epithelioma and demanded immediate operation. On May 23 I performed my usual operation for removal of the tongue, viz., preliminary ligature of the linguals and removal of the enlarged glands by the same incision and excision of the tongue by scissors. On examining the state of the glands through the submental incision, more were found to be involved than could be made out by external manipulation. They with the submaxillary glands were re- moved. Large drains were introduced into the mouth through the neck inci- sion, and the wound packed with Billroth's sticky iodoform gauze. This not remaining in more than a few hours, the wound was painted over with a paint of iodoform, resin, castor oil and alcohol, which formed a good antiseptic coating for the surface of the wound. The patient recovered well from the operation. He was fed by the rectum for three days; on the fourth day he sat up in bed and fed him- self with a tube; that evening he complained of a pain in the right side, and his temperature rose to 101°. Next day a well marked Iric- tion sound was heard. The wound was doing well, and the very slight fetor emanating from it was dissipated by a wash of Condy's fluid. On the sixth day his temperature was 103°, and respiration 41. He be- came very weak and rapidly sank, and died the next day. Dr. Lafleur who performed the autopsy has kindly given me the fol- lowing report : "External wound in neck healthy and granulating, Mound in mouth perfectly healthy without fetor and apparently healing kindly. In thorax was found a complete adhesive pleuritis of right side; adhesions are recent tearing easily. Similar recent adhesions over upper two- thirds of left lung. Surface of both lungs covered with nmeious mili - ary tubercles. On section, right lung from base to apex is crammed with gray miliary tubercles the size of millet seeds. Left lung on sec- tion also contains numerous miliary tubercles scattered throughout the upper two-thirds. In both lungs the tissue between the tubercles is intensely congested. No caseating bronchi-.l glands found ; bronchi normal in appearance; liver and kidneys contain. a few miliary tuber- cles. Pelvic organs normal ; epididymis of right tesucle is enlarged and on section found to be entirely caseous : vas deferens thickened, body of testis appears noimal. Left testicle and appendages nor- mal." "A microscopic examination of the growth on the tongue showed numerous tubercles in floop of ulcer, and around them abundant small EXCiSION OF THE TONGUE. 3 celled infiltration. Tubercles also found among the muscle fibres. Unaer high power numerous giant cells visible. The glands showed only a condition of inflammatory infiltration." There is now no doubt in my mind that the case was one of tuberculous ulcer of the tongue with perhaps a latent condi- tion of general tuberculosis which was lighted up into activity by the operation. The case is a unique one in my experience, and I do not see how one could have avoided the diagnosis of cancer. An intractable ulcer of the tongue with indurated base accompanied by enlarged sub- maxillary lymphatic glands occurring in an old man of 64, would naturally be looked up- on as of a carcinomatous character by most surgeons. The di- agnosis between tuberculous and cancerous ulcer of the tongue is always a difificult one, f • the lymphatic glands are involved in both diseases. Tuber iious ulcers have frequently been excised on the assumption that they were cancerous. In both diseases the same parts of the tongue are affected, the lymphatic glands involved and both may have their origin in injury, or, as in the present case irritation. The diagnosis of tuberculous ulcer is still more difficult when no other signs of tubercle are present, and when the disease occurs at an ad- vanced age. Excision of tuberculous ulcers is now a recog- nized method of treatment, and is one that offers the best chance of cure, especially when the disease is primary. The present case is interesting from the fact that there was not the slightest reason to suppose that the patient was pre- disposed to tubercle. The family history was good. His temperature, which was carefully taken for several days before operation, was perfectly normal. This joined with the fact that the tubercles were all of the same age, makes it probable that the general tuberculosis did not exist previous to the ope- ration. Whether the man was in a condition ripe for tubercu- losis and the operation was the exciting cause, or whether he became infected through the blood in consequence of the large wound it would, be difficulty to say. No doubt the infection came through the focus in the tongue and not that in the testi- cle. Cases of miliary tuberculosis occurring after operation are not common; still they occur, but usually after an interval 4 FRANCJS J. SHEPHERD. ot some weeks. Tuberculosis is well known to occur after fe- vers, such as typhoid, probably in such a lowered state of the system, the resisting powers of the individual are lessened, The rapid development of the tubercle in the case under dis- cussion is remarkable, and death was no doubt immediately due to the extensive pleuritis. As far as the operation is concerned, everything went well, and there was no post-mortem evidence that the patient died of any of the forms of S'^pticicmia which follow excision of the tongue. At one time it was thought that the ulcer might have been a cancerous one existing in a tuberculous subject, but a care- ful microscopic examination of the tongue and glands failed to show any evidence of carcinoma, while, on the other hand distinct evidence of tubercle was present.