Out of 61 operations personally per formed for malignant disease of the tongue, none died from the effects of the operation save 1, a male on whom Kocher's method modified was used; lie died of asthenia. Of the 61 cases, in 29 the disease returned. Many of these operations were performed, not with a view to cure, but merely to relieve and remove a foul, sloughing, foetid mass, and thus render existence more tolerable. Twenty-two cases were not traced di rectly, but it was learned indirectly that 5 were healthy three or four years after operation. Seven others had had no re turn of the disease, to personal knowl edge, one to fifteen years after operation, while 3 had no return seven, three, and two months after operation. It is ex pedient to ligate the external carotid be fore removing the tongue, tonsils, and part of the palate; but preliminary liga ture of the lingual arteries in excision of the tongue, as recommended by Mirault, is not required; there is no hmmorrhage from the ranine arteries to cause alarm; it is good surgery to re move the tongue first and then the dis eased glands later, if it is necessary to do the operation in two stages.
Thermocautery-scissors preferred when suitable. The tongue is held by toothed forceps, and just as the ranine arteries are about to be severed the hot blade is allowed to cool a little, in order to allow the arteries to bleed; they are then se cured and ligated. Frequent sprays are the best antiseptics. Wheeler (Dublin Jour. Med. Sci., Apr., '97).
New operative method in dealing with cancer of the tongue. Recent anatom ical research has demonstrated that the lymphatics of the tongue communicate not only Ivith the glands over the carotid and with those on the surface of the sub maxillary gland, hut also (I) with a sub mental gland lying on the inylo-hyoid muscle; (2) a gland in contact with the external jugular at the point of crossing of the omo-hyoid muscle: (3) some small glands in the muscle of the tongue itself near the hyoid hone. The lymphatics of the tongue also communicate very freely with each other. Hence, in operating in cases of lingual cancer the author argues that the lymphatic glands on both sides of the neck should be removed.
The operation is first performed on one side of the neck, and repeated after an interval on the other side. During the operation the lingual and facial arteries arc tied and the submaxillary gland re moved. At the third and final operation the tongue is removed by Whitehead's operation. Poirier (Revue de Chin, June, 11102).
Walter Whitehead, after an experience obtained in a large number of cases, recommends the following procedure: The patient is placed completely under the influence of the anTsthetic during the first stage of the operation, but after ward only partial insensibility is tained; the mouth is securely gagged and kept fully open throughout the oper ation; the head is supported in such a position, that while the best light is cured, the blood tends to gravitate out of the mouth rather than backward into the pharynx; a firm ligature is passed through the tip of the tongue for the purpose of traction. The first step in the operation consists in dividing the re flection of mucous membrane between the tongue and the jaw and the anterior pillars of the fauces. Rapid separation of the anterior portion of the tongue from the floor of the mouth is then made. If possible, the lingual arteries should be secured with Spencer Wells's forceps prior to division. A ligature is passed through the glosso-epiglottidean fold before finally separating the tongue. A mercurial solution should be applied to the floor of the mouth, and the sur face painted with an iodoform styptic varnish.
[In such operations the heat of the mouth tends to promote the development of infectious elements and fermentation, causing fietor. Puzey, in two cases, was able to thoroughly prevent the latter by hourly painting the whole wound with glycerin and borax. RumLiti[ :MATAS,
Assoc. Ed., Annual, '00.] Iiinorrhage is one of the most im portant dangers encountered during amputation of the tongue and subse quently. Secondary hmmorrhage is es pecially liable to occur when the wire or galvanocautery ecraseur is used, at the time the slough becomes separated. Whitehead's operation described above is done with scissors after the lingual artery has been ligated. But if this should give way, the following procedure recommended by Mr. Heath arrests the bleeding: The forefinger passed well down beyond the epiglottis is made to hook forward the hyoid bone and drag it up as far as practicable toward the sym physis menti. The effect of this is to stretch the lingual arteries so as to com pletely control for a time the flow of blood through them.
Antisepsis of the mouth until healing is complete is an extremely important feature of surgical measures. It should be frequently washed out or painted with a strong solution of borax.
ElocHER's OPER.A.TION.—Another dan (T t,er connected with excision of the tongue is septic pneumonia or broncho pneumonia, brought on through infec tion from the wound. This is prevented to a great degree by Kocher's method of excising the organ, the pharynx being plugged with carbolized sponges and iodoform gauze, after tracheotomy has been performed. The trachea is thus totally disconnected from the wound and no pus can enter it. The patient is fed by the rectum and by the mouth twice a day, when the oral dressing can be safely changed without involving infec tion for a few minutes. The operation itself is performed as follows: "An in cision is made commencing a little below the tip of the ear and extending down the anterior border of the sterno-mastoid muscle to about its middle, then forward to the body of the hyoid bone and along the anterior belly of the digastric muscle to the jaw. The resulting flap is turned up on the cheek and the lingual artery is ligatured as it passes under the hypo glossus muscle. Commencing from be hind, all the structures in the submaxil lary fossa are removed, viz.: the lym phatic glands, the maxillary, and if necessary, the sublingual glands. The opposite artery is now tied by a separate incision if the whole tongue is to be re moved. The mucous membrane along the jaw and the myiohyoid muscle are then divided and the tongue drawn out through the incision and removed with scissors or galvanocautery." AFTER-TREATMENT.—More than ordi nary attention must be given to this feature of the operation. We have seen the dangers accruing from the gravita tion of pus into the bronchi, septic in fection from the wound, etc. Before, during, and after the operation the mouth should be kept as aseptic as pos sible by means of borax or permanga nate-of-potassium solution, 20 grains to the ounce of the former, and 1 grain to the ounce of the latter. After the oper ation Whitehead washes the parts with a solution of perchloride of mercury, dries it thoroughly, then applies an anti septic varnish composed of the ingredi ents of Friar's balsam, but substituting a saturated solution of iodoform in ether. This he found to be more comfortable to the patient than gauze or lint. Some surgeons prefer to pack the cavity with moist iodoform gauze—made with glyc erin and rosin dissolved in alcohol. Mansell-Moullin cuts this into strips, packs the whole cavity with these, laying them flat one upon the other with fresh iodoform between until the wound is filled. The deeper layers adhere to the raw surface, from which they cannot be separated until it has begun to granu late; the superficial ones sodden with saliva may be removed from time to time. At the end of a few days the whole comes away itself, leaving a heal ing surface beneath.