CLINICAL REPORTS.

SUB-LINGUAL CYST.

PRESENTATION OF PATIENT, DESCRIPTION OF OPERATION AND DEMONSTRATION OF MICROSCOPIC SECTION.*

WILLARD BARTLETT, A.M., M.D.*

On the 15th of September, 1905, I was consulted for the first time by Mr. G., 38 years of age, a native of Germany, a brewery laborer. At that time he was apparently in the enjoyment of good health, and complained only of the presence of a lump in the floor of his mouth. This had been first noticed in 1900. It caused him no trouble until June, 1904, at which time it commenced to enlarge, and two months later he was suddenly taken with embarrassment of speech, swallowing and breathing. These symptoms became so alarming, that he was obliged to send for a doctor hurriedly in the middle of the night, because he feared suffocation. This physician immediately lanced the new growth, and the patient was instantly relieved of all his urgent symptoms, by the liberation of a large quantity of a mucus-like fluid.

A day or two later, the above mentioned opening was enlarged, and the interior of the cavity scraped out with a sharp spoon.

When I first saw the patient, some fourteen months after the events above narrated, he stated that he had just discovered the old lump in the floor of his mouth once more, and was greatly apprehensive of a return of all the old dreaded manifestations. On physical examination, I found the entire space, between the

*Read before the Alumni Assoclation of the Medical Department of Washington University, Feb. 12, 1906.

tongue and lower teeth, on the right side, filled out by a bluish oval mass, apparently lying just beneath the mucous membrane, and somewhat larger than a filbert nut. This was rather freely movable on its base, and gave the impression of being tightly filled with fluid, so tightly, in fact, that very little fluctuation. could be elicited. The mucous membrane was freely movable over the mass, but decidedly thinned out, with its blood vessels tightly stretched across the field. After this time, I saw nothing more of the patient for three months, when on December 20th, on arriving at the hospital I found him there in a most desperate plight, and earnestly begging for the operation, which had been advised on the occasion of his former visit. The day before, he had noticed the beginning of a sudden increase in the size of his tumor, and, at once, had foreseen a re-occurrence of all his old symptoms. The whole region of the mouth and pharynx had commenced to feel sore, as though he had contracted a violent catarrh of them. He commenced to feel sick and depressed, and as the tumor continued to enlarge, he became unable to speak, while breathing was greatly interrupted, and swallowing became almost impossible. With every attempt at the latter function, there occurred a most violent spasm of the muscles employed, and this was so painful, and caused him so much alarm, that his condition was rendered apparently desperate thereby.

On physical examination at this time, I saw that the mass, which had formerly been limited to the right side, had now increased so greatly in size, as no longer to respect the frenum of the tongue, but had dissected its way across the median line into the left side, and had assumed a more or less horseshoe shape, being many times as large as the filbert nut, originally quoted. It was very tightly filled with fluid, was slightly fluctuating, and on bi-manual examination, could plainly be felt, beneath the chin, extending back to the vicinity of the hyoid bone. Its size was so great, that the tongue had been bodily pushed upward

and backward, until it lay firmly against the roof of the mouth. The patient was unable, at the same time, to close his jaws. He had to sit up to get his breath, and was almost in desperation, in consequence of pain and fright. Apparently the backward pressure upon the base of the tongue was sufficient to force down the epiglottis, or, at least, partially to close the pharynx, if any conclusion was to be drawn from an observation of his breathing.

It was very apparent that something must be done, but I hardly cared to risk a radical operation, under anesthesia, on a patient in his condition, nor did I care to repeat what had been ineffectual, namely, lancing of the cyst, with consequent infection of its interior; hence temporary palliative treatment was resorted to. An ice collar was applied, morphine injected, and a mouth wash, containing cocaine, frequently used. Under the employment of these measures, his condition improved somewhat during the next twenty-four hours.

On December 21, 1905, he was operated upon, and my reasons for undertaking the rather formidable procedure of dividing the lower portion of the face, in order to afford access to the tumor, were the following:

It was impossible to gain sufficient room to do the work through the mouth, especially in view of the fact that I would, in stripping out the cyst wall, have to go as far back as the hyoid bone. On the other hand I did not attack it from the skin side of the floor of the mouth, for the reason that it lay between the mucous membrane and the muscles, and this would not have afforded sufficient room, and in addition, would have been a very indirect route. Again, this thing had been already tampered with twice, and I felt that whatever should be done, must be final and effective. Hence, I divided, in the middle line, the lower lip, lower jaw, and the floor of the mouth, more than half way back to the hyoid arch, and then, by drawing these two halves forcibly asunder, was able to get at the exterior of the cyst, without the

slightest difficulty, and to skin it out completely in a very short time. It was seen to lie between the muscles and the mucous membrane, was fairly free of adhesions everywhere, except at its lowest point, where it was firmly attached in the vicinity of the hyoid bone, by a strong fibrous pedicle. It proved to have but a single chamber, and its contents consisted of a thin, colorless fluid, in which floated a large number of grayish, pasty flocculi. It is interesting to note, as you can observe for yourselves, by examining the patient, that the jaw was divided in exactly the middle line with Gigli saws, without the injuring, or sacrificing of a single tooth. The anesthetic, as administered, in this case, deserves more than a passing mention. Ether was used by pouring it upon cotton, stuffed into a glass funnel, which communicated through a long rubber tube, with a glass "Y," held near the patient's face. Attached to either limb of this "Y" was a heavy rubber catheter, which had been introduced through the nose into the naso-pharynx. Then to prevent blood getting into the respiratory apparatus, the space between the tongue and roof of the mouth, which in this case was very small, was firmly packed with gauze. Just as the removal of the cyst was almost complete, the man suddenly became intensely blue and stopped breathing. Artificial respiration was immediately introduced, the tongue drawn forward, and even the epiglottis lifted with the finger. But, all this did no good, so, three or four minutes later I simply plunged a knife into the trachea, at a single stroke, then introduced the handle through the incision and turned it sideways to hold the tube open. This immediately had the desired effect, the patient took a deep inspiration, and in a few seconds his blood was of the desired color. A metal tube was tied in place, and the operation proceeded with. Then the mucous membrane, periosteum, muscles and skin were all sewn, in separate layers, no attempt being made to reunite the bone as such. A little drain was left at the posterior angle of the skin

incision.

As might be expected all the patient's symptoms were immediately relieved by the operation. He was up in a few days, his wound healed beautifully, and the union in the lower jaw is, as you will see, perfect, the same having been treated for me by Dr. Prinz the day after the operation, by the teeth being wired together, laterally as well as the upper to the lower. The patient was out of the hospital in a few days, and is now shown you seven weeks after the operation.

The diagnosis, sub-lingual cyst, can be regarded as of clinical significance only, and while a more exact differential diagnosis is scarcely of practical interest, under circumstances like those which surrounded this case, still it is of sufficient scientific interest to justify a few words in this connection.

The tumor under discussion can hardly be a cyst originating in a salivary gland, or duct. These are never of large size, they contain saliva, and tend to spontaneous cure in one of two ways. After the pressure reaches a certain point, the gland which supplies it will atrophy: while a cyst of a duct frequently bursts and leaves a salivary fistula, or else shrinks and disappears.

A thyro-glossal cyst does not resemble that under discussion, because it is multilocular, lies exactly in the middle line, and where it is under the tongue at all, occupies the fat space between epiglottis and the hyoid bone. When examined under the microscope it is seen to be lined with ciliated columnar epithelium.

The dermoids on the floor of the mouth present a clinical picture which does not answer to that here presented. They lie exactly in the middle line, are of yellowish color, possess a consistence which is similar to that of putty, and according to Rosenberg (Deutsch. Med. Woch. 1894) originate in the mesobranchial space.

The fourth cyst form to be considered in this connection is the ranula, of which form we have here, undoubtedly, an example.