Chapter VIII

.)

_Leukoplakia_ implies the appearance of opaque, white patches upon the mucous surfaces of the tongue as well as on the lining membrane of the mouth, lips, and palate. They are far more frequent, however, on the tongue and generally appear there first. Here they appear almost as if thin scales could be separated from the surface upon which they lie, but this will not be found possible when the effort is made. The patches are irregular, but sharply outlined, occasionally confluent, involving the entire upper lingual surface; while the plates become harder and more roughened as they grow older, and furrows, subsequently ulcerating, may appear between them. The affection is chronic and intractable. It occurs often in the mouths of smokers during middle and advanced life. While its etiology is unknown it may be due to chronic irritation.

_Between leukoplakia and epithelioma_ of the part involved there seems to be a strong relation, and the former is often regarded as a precancerous stage of the latter. Epithelioma is a frequent terminal feature of leukoplakia. There often seems, moreover, a predisposition to it in syphilitic individuals. It is mainly to be distinguished from secondary syphilitic lesions, which may be done by recalling its chronicity and its obstinacy to the treatment which would disperse the latter.

In the way of _treatment_ smoking must be prohibited, antiseptic mouth-washes often used, with cauterization to a mild degree. These methods, however, suffice only for the milder cases. If any caustic be used it may be either 10 per cent. chromic acid, chemically pure lactic acid, or nitric acid, caution being used in their application. The more serious forms of leukoplakia will usually yield to local anesthesia, followed by curetting of each patch until the raw surface beneath is exposed, and then the application of the actual cautery. Rigorous treatment is necessary when ulcerated and fissured patches are present.

The _benign tumors of the tongue_ include nevi, often in connection with single or multiple papilloma, or which may assume the type of multiple papillomas, each of which is extremely vascular. Occasionally the tongue will be seen almost covered with these small growths. This condition is noted usually in young children, and is practically of congenital origin. It frequently subsides spontaneously, but may require the actual cautery or something equally radical. The other benign tumors are of occasional occurrence, even an enchondroma having been occasionally seen. Much more common are the _retention cysts_, especially that particular form of cyst occurring beneath the tongue or at its base, known as _ranula_. This term is vaguely applied to cysts produced by obstruction of one of the salivary ducts or by cysts of congenital origin. It is caused mainly by incomplete obliteration of the thyroglossal duct. A so-called ranula may contain colorless fluid, more or less thick, and mixed with epithelial or dermoid products.

[Illustration: FIG. 472

Macroglossia. (Tillmanns.)]

It is possible to extirpate nearly all of these growths through the mouth, with aseptic precautions.

_Macroglossia_ is a condition of congenital enlargement of the tongue, due mainly to a form of lymphangioma, which may be accompanied by vascular papillomas or alteration of the mucous covering. Such a growth will produce enlargement of the tongue to an extent that does not permit of its retention within the mouth. Excision of a V-shaped portion sufficiently large to reduce the tongue to proper dimensions is usually requisite in these cases (Fig. 472).

Of the _malignant tumors of the tongue epithelioma_ is by far the most common. It is rarely seen in women, and not often before middle life. Here more than in almost any other part of the body the possible causative factors of irritation and trauma are present, jagged teeth furnishing the usual source of each. It is known also to be a frequent sequel of _leukoplakia_ and of various chronic ulcerations and other lesions. Other benign growths occasionally alter their type and become epitheliomatous. It occurs usually on the exposed surface, and tends quickly to an ulceration whose border is indurated and often fissured. It is ordinarily distinctive in its appearance, but occasionally needs to be differentiated from lesions of syphilis, tuberculosis, and actinomycosis. Lymphatic involvement occurs early in each of these conditions and may be confusing. A suspicious ulcer which tends constantly to deepen and increase in dimensions, accompanied by marked induration and lymphatic involvement, and not benefited by antisyphilitic treatment, will generally prove to be epitheliomatous. As the lesion extends there is involvement of all the surrounding structures--the floor of the mouth as well as the pharynx, the salivary glands, and even the lower jaw itself. When pain is felt it is usually referred to the region of the ear. There will be, naturally, interference with all the functions of the mouth, as well as with speech, while starvation, septic infection, and hemorrhage may terminate the case.

In no part of the body is prognosis more unfavorable. Recurrence, even after early and radical operations, is usually unavoidable, and it is doubtful if 10 per cent. of cases of epithelioma of the tongue are free from disease at the expiration of three years after removal.

Treatment should be prompt and radical. It consists of _extirpation_, which must be extensive to be effectual. A small cancerous ulcer on one side of the tongue may justify removal of one-half of the organ, but, under nearly all circumstances, it is best to make a complete removal of the tongue. This may necessitate a formidable operation, and may be expected to materially interfere with speech; but that it does not prevent it is shown by the fact that in medieval days, when tearing out the tongue was a means of punishment or torture, men were often still able to speak intelligibly.

Inoperable cases should be made comfortable with cleansing mouth-washes and applications of local anesthetics, coupled with such anodynes as it may be necessary to administer. Resection of the lingual nerve will sometimes relieve the intense pain, while proximal ligation of the lingual artery may arrest rapidity of growth. It is in these inoperable cases that Dawbarn’s suggestion of the extirpation of the external carotid artery, first on one side and then on the other, may be put into practice, the intent being to so completely shut off circulation as to check growth. In some forty cases or more it has given results as satisfactory as could be expected.

OPERATIONS UPON THE TONGUE.

Operations upon the tongue include _partial excision_ and _complete extirpation_, perhaps with much of the adjoining tissues. Here, as in every operation, the mouth should be thoroughly cleansed. Before extensive operations a preliminary ligation of the lingual artery should be made on both sides, just above the hyoid bone. (See p. 352.)

A small lesion at the tip of the tongue may be excised by a wide V-shaped removal of the anterior part of the tongue, under cocaine anesthesia, the edges of the opening being brought together with sutures of silk or of chromic catgut, for ordinary catgut would be too quickly macerated when thus soaked in the mouth. The lesion may be so placed as to not permit of this V-shaped opening being symmetrically placed. The same rules, however, will apply, the operation being performed with a sharp-bladed bistoury or with sharp scissors, bleeding vessels being seized with forceps as they are cut. These clean removals give more satisfactory results than the old operations performed with the écraseur or cautery. A _complete excision of the lateral half_ of the tongue is easily made through the mouth, the organ being controlled by a stout suture passed through the other portion. The vessels and lymphatics of the tongue do not cross its septum, and all the hemorrhage that need be anticipated will come from the side attacked; but when it is necessary to remove an entire half of the tongue the case has usually progressed to such an extent that its complete removal will be usually indicated and will be more effectual.

Of the various complete operations upon the tongue but three will be described here.

_Whitehead’s_ operation comprises an almost total extirpation made through the mouth, without division of cheeks or lips. The patient is placed in a semi-upright or upright position. The mouth is held open with a mouth-gag, for which purpose none serves better than the O’Dwyer gag used for intubation. The operation is begun under brief but complete anesthesia, and is usually completed before the patient has recovered from it.

The tongue being secured with a stout suture passed through it, its frenum and its attachment to the fauces are divided, along with all other reflections of the mucosa. Vessels which spurt should be caught at once. General oozing may be disregarded. After being thus freed the tongue is pulled forward, a strong suture passed through the glosso-epiglottidean fold, and then with sharp, slightly curved scissors the entire organ is cut away from its base, the lingual arteries being seized the instant they are divided. The operation is bloody for the few minutes required for its performance, but is quickly done and with a minimum of disfigurement. By the last-mentioned suture the stump can be pulled forward, should the epiglottis tend to drop backward and disturb respiration, or should hemorrhage require. After its conclusion, and during the after-treatment, frequent warm, antiseptic solutions should be used for washing the mouth, and it is the practice of some to paint the raw surfaces with a styptic varnish, made of balsam and saturated solution of iodoform in ether. In order to avoid the passage of saliva downward the patient is encouraged to sit up and to expectorate freely rather than swallow infected saliva.

The _Regnoli-Billroth operation_ is performed by turning down a horseshoe-shaped flap, its convexity being taken from the symphysis of the jaw, and thus opening into the mouth from below. After making the opening sufficiently wide, the tongue, through which a traction suture has been passed, is pulled through the submental wound and its base divided with scissors. Should it be difficult to locate bleeding points in the stump a finger may be hooked in the pharynx and the latter pulled forward. The submaxillary wound is then closed with sutures, with one drain.

[Illustration: FIG. 473

Lines of incision for total excision of the tongue. (Chalot.)]

The most complete of these operations is that described by Kocher. It permits of removal of the tongue, of the floor of the mouth, of all infected lymphatics, and even of a portion of the jaw if this be necessary. A line _A-B_, Fig. 473, may offer sufficient exposure by incision, but the line _C-D-E-F_ will permit more complete attack. Through this incision a flap is raised, the facial vessels being ligated. All lymph nodes are extirpated, as well as the salivary glands, if necessary. After separating the mylohyoid from its insertion in the inferior maxilla the mouth is opened and the tongue drawn out through the incision, where it may then be kept under perfect control. It will facilitate matters if the lingual arteries be secured before the entire tongue is cut away. In some cases a preliminary tracheotomy is considered advisable, largely because the performance of the operation interferes with the administration of the anesthetic in the ordinary way. Should it be done the pharynx should be tamponed until the conclusion of the operation. The trachea tube may be immediately removed or left, as seems advisable, while the patient is fed for several days with a stomach tube.

Operations suggested by Sédillot and Langenbeck include division of the lower jaw in such a way that by separation of its portions a more complete exposure of the floor of the mouth is afforded. They are at present rarely adopted, unless extension of the disease to the bone should necessitate excision of some portion of the jaw itself.

THE TONSILS.

The tonsils are the most conspicuous portion of the ring of lymphoid tissue which extends completely around the original opening connecting the exterior of the face with the upper end of the neurenteric canal. This tissue is particularly inflammable, and this may account for the frequency with which severe infections of the tonsils occur, and the marked toxemia which complicates even mild degrees of the same. In this lymphoid, or, as it is usually called, “_adenoid_” tissue, crypts and follicles abound, and in these latter all sorts of infectious materials accumulate. Thus acute infections, as well as chronic hypertrophies due to pressure and irritation, are extremely common.

The various forms of _angina_, _i. e._, _sore throat_, have to do largely with expressions of these infections in varying degrees of severity. The adjoining mucosa and other tissues frequently

## participate, and it is possible to produce a painful degree of

chemosis of the membranes involved in a short time. Adjoining lymph involvement, with discomfort or even distress in the region of the throat, and sometimes pronounced general malaise, are extremely common accompaniments.

The “cynanche tonsillaris” of the older writers implied an acute expression of this kind, often with more or less exudation, which, accumulating upon the exposed surfaces, produces there a membrane, the condition being most noticeable in the pronounced types of diphtheria. At other times activity is manifested rather in the peritonsillar structures, and acute and suppurative types of cellulitis, leading either to abscess in the tonsil or deep in the neck, are the result. A surprising degree of toxemia accompanies these lesions and sometimes severe and fatal general septic infection, perhaps with endocarditis. _Abscess of the tonsil_ may produce so much occlusion of the pharynx as to make breathing difficult and even almost impossible, perhaps even to a point requiring tracheotomy. Tonsillar abscesses usually evacuate themselves in time; if they are opened by the surgeon relief comes promptly, with evacuation of pus, no matter how brought about.

Many such abscesses could be easily recognized and incised were it not for the surrounding inflammation, which prevents the patient from opening the mouth sufficiently wide to expose the pharynx. Suffering in these cases is acute.

A swollen and fluctuating tonsil, if it can reached, is easily perforated by a sharp, straight knife. Erasion and fatal perforation of the carotid artery has been known to be a sequel of such a case unrelieved. Again, pus having its source within the tonsil may burrow in such a direction as to produce a retropharyngeal abscess.

The tonsil is rarely the site of primary _syphilitic_ lesions, more often of the secondary, and occasionally of _tuberculous_ lesions.

The most common chronic affections of the tonsils result from failure of absorption of inflammatory products after acute inflammations, which leaves a permanent enlargement, and which is constantly irritated and provoked into further growth by the retained contents of the tonsillar crypts. It is in this way that _chronic hypertrophy_, or the so-called _enlarged tonsils_, result. These conditions are especially common in children, presenting the milder forms of the status lymphaticus. (See

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