Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

Clinical Features.—The clinical appearances vary widely. Sometimes the surface presents a warty growth; sometimes it is excavated, forming a deep ulcer with raised nodular edges; in other cases the ulcer is smooth, and its edges even and rounded. Extreme hardness of the edges and base of the ulcer is always a characteristic feature. The tongue tends to become fixed, especially when the disease spreads to the floor of the mouth, so that it cannot be protruded, and the restriction of its movement produces a characteristic interference with articulation, certain words being slurred, and when the fixation is extreme it may interfere with mastication and swallowing. The patient complains of a constant gnawing pain in the tongue, and of severe pain shooting along the branches of the trigeminal nerve, and especially towards the ear. In the advanced stages there is salivation and fœtor of the breath.

When the disease is situated on the edge of the tongue it tends to spread to the floor of the mouth and the muco-periosteum of the mandible. If situated far back on the dorsum, it spreads on to the epiglottis, the pillars of the fauces, and the tonsil.

The neighbouring lymph glands—particularly those under the jaw and along the line of the carotid vessels—soon become infected and are palpable. The submaxillary and sublingual salivary glands are also liable to be affected. The enlarged cervical glands later undergo softening, or suppurate and burst on the skin surface, forming fungating ulcers. Metastasis to the liver, lungs, and other viscera is exceptional. If the disease is allowed to run its course, the patient usually dies in from twelve to eighteen months from repeated small hæmorrhages, toxin absorption, or septic broncho-pneumonia.

Differential Diagnosis.—Cancer of the tongue has to be diagnosed from syphilitic and tuberculous affections, from papilloma, and from simple ulcer and fissure. It is to be borne in mind that any of these conditions may take on malignant characters and develop into epithelioma. The microscopic examination of a portion of the growth removed under local anæsthesia from the base of the ulcer at some distance from its epithelial core is often the only certain means of establishing the diagnosis, and should be had recourse to as early as possible. When there is still doubt as to the nature of the growth, it should be treated as if it were cancerous.

An unbroken gumma is liable to be confused only with the uncommon form of epithelioma which begins as a nodule under the mucous membrane. Gumma, however, are often multiple, and the tongue shows old scars or other evidence of syphilis.

Gummatous ulcers are usually situated on the dorsum, are frequently multiple, and have sloughy, undermined edges; the surrounding parts, although indurated, are not so densely hard as in cancer; there is not necessarily any involvement of lymph glands. The cancerous ulcer is usually single and situated on the margin of the tongue; its edges are hard, raised, and nodular; and the glands are usually enlarged and hard. Little reliance is to be placed on the therapeutic effects of anti-syphilitic drugs in the differential diagnosis, as they are often inconclusive, and their use results in loss of time.

Tuberculous ulcers usually occur in association with other and unmistakable evidences of tuberculosis. A papilloma, when sessile, may simulate cancer; these tumours show a marked tendency to become malignant. Simple ulcers and fissures are usually recognised by the history of the condition, the absence of induration and of glandular involvement, and by the fact that they heal quickly on removal of the cause.

Treatment.—The only treatment that offers any hope of cure is free removal of the disease, and experience has proved that unless this is done early the prospect of the cure being a radical one is remote. Not only must the segment of the tongue on which the growth is situated be widely excised, but all the lymphatic connections must also be removed whether the glands are palpably enlarged or not.

The chief risk after operation is pneumonia resulting from the inhaling of blood and products of infection: hence the importance of rendering the mouth as dry and as sweet as possible before operation, special attention being paid to the teeth, and precautions being taken at the operation to prevent the passage of blood down the trachea. The patient is usually able to be out of bed on the second or third day, and is well in a fortnight or three weeks. The operation, even when followed by recurrence, usually prolongs life by six or eight months, and renders the patient more comfortable by removing the foul ulcer from the mouth. The speech, although impaired by the removal of one-half or even more of the tongue, is distinct enough for ordinary purposes. When recurrence takes place it is usually in the glands, and may be attended with great suffering.

Treatment of Inoperable Cases.—The mouth must be kept as sweet as possible. The pain may be relieved to some extent by cocain or orthoform, but as a rule the free administration of morphin is called for. Pain shooting up to the ear may be relieved by resection of the lingual nerve, or the injection of alcohol into its substance. If hæmorrhage takes place from the ulcerated surface and cannot be controlled by adrenalin, or other local styptics, it may be necessary to ligate the lingual, or even the external carotid artery. Interference with respiration may necessitate tracheotomy. When the patient has difficulty in taking food, recourse should be had to the use of the stomach-tube or to gastrostomy. The use of radium or of the X-rays appears to have a restraining influence on the disease in the glands, but has not proved curative.