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THE operation which I intend discussing in this paper is that introduced by Prof. Billroth, of Vienna, viz., ex- cision of the tongue by scissors, with preliminary ligature of the Unguals. In excising the tongue for malignant disease, be- sides the necessity for avoiding danger from haemorrhage, it is important that structures in the neighborhood, which have be- come involved, should be removed, and the operation which facilitates this removal, without running much additional risk, is the one to be preferred. Billroth's operation, in my opinion, fulfils these conditions, and the mortality following it is not greater than that of other operations for removal of the tongue. In most of the English and American text-books on Surgery it is but briefly or not at all mentioned. Ligature of the lin- gual artery is described, certainly, but only as an operation to be performed on the dead subject, the difficulties and dangers at- tending its performance on the living subject are passed over.* I shall briefly describe Billroth's operation, mentioning the difficulties I have met with in performing it. ' Read before the Surgical Section of the Canada Medical Association, Septem- ber, 1885. ' Since writing the above Mr. Henry T. Butlin's admirable work on *' Diseases of the Tongue" has appeared, in which the various operations for removal of the tongue, including ligature ol the lingual are fully described. *, ^^^^y^^^m^ #■ \ - > ' Operiition. — The head of the patient having been wfcll tliroWA back and the chin turned to the side opposite to that on which the artery is to be tied, a curved incision is made from near the symphysis menti to near the angle of the lower jaw, the convexity downwards, having its lowest portion running along the upper border of the great cornu of the hyoid bone ; a care- ful dissection is then made through the platysma and deep cer- vical fascia, and if any veins are cut they should be ligatured before proceeding further with the operation. The tendon of the digastric muscle should now be searched for, and in the angle this tendon forms with the hyoid bone, the artery will be found- — but not immediately, for covering it we have the hyo- glossus muscle with the hypoglossal nerve and ranine vein run- ning over it. The hyoglossus muscle should be carfuUy di- vided and then, all bleeding having been arrested by Pean's forceps and ligatures, the artery is felt pulsating at the bottom of the wound. Haemorrhage should now be completely arrested and the artery being brought into view can be easily tied. I have been in the habit for some time past, when ligaturing arteries, of placing two ligatures on the vessel and cutting be- tween them, and I do the same when ligaturing the lingual. By this method we are certain of the artery being occluded, .and cannot easily mistake it for the large vein which sometimes .accompanies it. The artery on the opposite side having been :secured in the same way, any glands that may be involved :should be looked for and removed through these incisions in the neck. As a rule, they can be found without difficulty. In all my cases I had to remove the submaxillary gland of one side, and in two, some of the cervical glands. If the submax- illary glands are not involved they should be treated tenderly and not cut into,, as afterwards they may take on troublesome inflammatory action. The mouth should now be kept open with a gag and the tongue drawn out b> v. double ligature passed through its sub- stance about an inch from the tip. The operator, holding the lig- ature in his left hand, draws the tongue outwards and upwards and removes it with a straight pair of scissors. The attach- ments of the tongue to the jaw and pillars of the fauces should first be freed and then the muscles at the base, and the attach- ^ar^KZ '^•.. ^' /' ment to the hyoid bone divided with a few short cuts, an4 the whole tongue will come away, leaving the epiglottis behind^ The removal of the tongue takes, as a rule, only two or three minutes. If the tissues' of the floor of the mouth be involved, they should now be attended to. The wounds in the neck, which during the excision of the tongue should be filled with carbolized sponges, are then sewed up with catgut or silk ligatures and dressed with iodo- form and pads of jute or cotton wool. If the floor of the mouth has been removed it will be better to pass a large drain- age tube into the mouth through the neck incision; in fact, this ought to be done in every case. The mouth is now packed with iodoform gauze and the operation is complete. The after-treatment is the same as after excision of the tongue by other methods, and I shall not now discuss it. The difliculties of the operation are not so great as I had expected, and any one with a fair knowledge of the anatomy of the parts, and some experience in operating, can easily over- come them. The following points are worth remembering in performing the operation : (i.) The veins in the neighborhood of the hyoid bone (such as the facial, anterior division of the temporo-maxillary and the trunk formed by these two) are fre- quently of large size, and if wounded give rise to tremendous haemorrhage, so if possible, when seen, they should be le|. •^adng the lung under water* and blowing air through the pulmonavy ^ery« bubbles escaped from one of the gangrenous regions close to :1^e root of the lung. Dissection showed that the haemorrhage came from a small branch of one of the main ^Visions o'. the bronchial artery which had been opened in the necrotic process. The bad result of the operation was in no way du^; to the mtmner in which it had been performed. The wound in tb;; neck healed with- out difficulty and added nothing to the risk. The erysipelas was no doubt developed from a case which had been inadvertently admitted into the same ward a few days before.. « • ' ' " Case II. Thos. K., aet. 54, a tall, spare man, of intemperate hab- its and an inveterate smoker, was brought to me by Dr. Geo. Ross, February. 34, 1884, suffering from cancerous disease of under surface of the tongue and the gum lining the inner side of the middle of jaw. Four months ago first noticed a lump under right side of tongue which increased rapidly in size and soon ulcerated. Had, when first seen, a hard cancerous growth involving the whole of the under surface of the tongue neslr the root, the floor of the mouth and the gum lining the lower jaw. The submaxillary glands and deep cervical glands muc^ enlarged. Removal of tongue and floor of mouth decided on. The operation was performed February 25, 1884. The Unguals were first tigatured by same incision as in previous case. The ligature of the right lingual was rather difficult owing to the great enlargement of the submaxillary gland. The gland was removed and facial tied as well. The ligature of left artery was comparatively easy, except that a large vein at outer edge of wound was wounded and gave rise to considera- ble haemorrhage, which, however, was soon stopped by a Pean's for- ceps and the vein tied. The left submaxillary gland was not taken aWay. Through the incisions in neck some enlarged cervical glands were re- moved. Both arteries were tied in two places with catgut and divided between the two ligatures. They were large and tortuous.' After draw- ing out the tongue by a ligature placed a short distance from the tip, it was removed by scissors. The whole tongue was thus removed without difficulty and without haemorrhage. The diseased gum and the floor of the right side of the mouth was then dissected away, leav- ing free communication between the external wound and the mouth,. The wounds in neck were then sewed up with catgut and on the right aide a large drain put through . the wound into the mouth ; the mouth was packed with iodoform cotton wool. The patient did very well, the temperature not rising ^above 99°. Every day for the first week c'"' \: 'ft ''I ■"';■*• i liln W^^^^^^^^K^^^^^W^^-''^!^^^^^^/?- '-'>* ['. '>'- I. the mouth was washed out by metos of the drainai;e tub6 and thepa^ck- ing: daily replated. The wound in the neck healed by first intention e^- ,«6{>t where drainage tube remained, and there never was the slightest trace of fetor. As in the first case, the patient was fed per rectum the first few days with beef tea and brandy, and after that he took his nourish- ment by the mouth. In three weeks the patient went home with the mouth wound all healed and only a small fistulous opening in neck where drainage tube had been. The disease returned in floor of mouth two months after the opera- tion, but his general health remained good. By July the growth had increased considerably and in September he began to have heemor- rhages, till finally he died of exhaustion September 21, 1884, about seven months after the operation. ^U Case III. Wm. H., set. 60, a robust, healthy looking man, carter, came to the Montreal General Hospital May 14, 1884, complaining that he had a sore under his tongue which was very painful and which was rapidly getting worse. Some months ago first noticed a small lump on the under surface of the left side of the tongue", this gradually increased in size till four weeks ago, when it broke and left an ulcer. On examination a foul, slough-looking ulcer, size of a twenty-five cent piece, with ragged edges and a hard indurated base, was found on the under surface of the . tongue a little to the left of the frenum. The submaxillary glands of that side and the deep cervical glands were enlarged and indurated. Diagnosis, malignant diseaise. The operation of removal of the tongu6 was performed on May 15, 1884. The Unguals were tied by the sam6 incision as other cases. The right artery was tied without much diffi- culty, except that the digastric tendon was bound down to the hyoid bone to a'greater extent than usual and had to be separated. On the left side, owing to the great enlargement of submaxillary gland, the space be- tween it and the hyoid bone was much constricted and the artery was secured with greatest difficulty. In the dissection the large temporo- facial vein had to be tied. The submaxillary gland of this side was then removed and the facial artery tied, and by extending the incision outwards the enlarged cervical glands which were on the sheath of the vessels were removed. The tongue was then excised with scissors in the usual way without haemorrhage ; but as the last snip was made the epiglottis fell back and almost asphyxiated the patient. I immediately introduced my finger, turned back the epiglottis and passed a catgut ligature through and made it fast outside the mouth. The wounds in the neck which had been filled with carbolized sponges were now well W9s^^ out with bichloride solution and sutured. As there was an open* ing into the mouth on the left side owing to the extensive dissection of the floor oi mouth and remova,! of the submaxillary gland, a large drain* age tube was passed into the mouth. The wound was then dressed with iodoform gauze and borated cotton and a bandage applied. The -mouth was also packed with the same gauze and then the operation was complete. The patient recovered well from the operation. He was fed per rectum for a week and the dressings in mouth and left side of neck re- moved daily, and the parts thoroughly washed through the large drun- age tube. By the end of the first week the wounds in the neck, ex- cept where drainage tube passed into the mouth, were healed by first intention and the mouth wound was looking healthy and healing rapidly^ It was found that the patient was totally unable to swallow liquids, so he was fed by a tube passed into pharynx. By June i the wound in the mouth had healed entirely and the only part that remained un- healed was the fistulous opening where the drainage tube had been. The patient was very self-willed and of an irascible disposition and fre- quently used to get up at night in spite of the nurses and walk about. He in this way contracted a bronchitis which kept him in hospital longer than he otherwise would have been ; his breath and expectoration were fetid, the latter was very profuse. He still was unable to swallow fluids, but could take solids fairly well, so he was still fed with the pharyngeal tube. He left the hospital June 17, a little more than a month after the operation. In January, 1885, eight months after the operation, he came to see me and at that time he had some enlarge- ment of the glands of the neck, but mouth was perfectly clean. He still had to take his liquids by means of a tube, which he passed him- self; his family told me that nothing would induce him to attempt to swallow liquids without the tube. In June, 1885, the glands on both sides of neck were enlarged and he had some induration in floor of mouth ; this gradually increased and he failed rapidly, dying of exhaus* tion July 29, 1885. Although the results in these three :/perations are not very brilliant, still I feel that had I similar cases to deal with again I would operate in the same way. In all three cases the disease was Very extensive and not confined to the tongue alone, the involvement of the glands being a marked feature. In such cases any attempt to remove the diseased structures, without ^e neck incisions, would have been as useless and as unscien- ■ -"^m 10 I tific as operating on cancer of the breast andallowiiig the enlarged glands in axilla to remain without extending the in> cision to remove them. In the two cases which lived the relief was evident, though in Case II not so permanent as one could have wished. In Case I the neck wounds were in no way re- sponsible for the fatal result and in the other two cases did not retard recovery, but, on the contrary, rather hastened it by the greater facility afforded for drainage and thorough washing of the mouth. 5; ^ In each of the three cases removal of the tongue was re- markably bloodless and even the ligature of the Unguals was not attended with an\ haemorrhage worth mentioning. The facility with which the affected glands were removed through the neck wounds was very great. w J. H. CHAMBBBS * CO., FtTBLUBCBB AMD IMAI.KM IK UM± GAL BOOKS. 914 Loonat 8t. , St. trf>ula. \ rjiV^^ ' iY\ "^'ii V /■ >wiiig the tg the in- the relief >ne could > way re- ;s did not it by the ashing of e was re- ;uals was ng. The I through w