Elements of Surgery

by Robert Liston

past the meridian of life. Yet I have seen the greater part of the tongue involved in carcinomatous swelling in young subjects; from one girl, twelve years of age, I was obliged to remove one-half of the organ vertically. Stony induration surrounds the exposed surface to a considerable extent, and the sore presents all the characteristic appearances of cancer. In many cases the induration precedes ulceration, in others follows it. A most extensive and dreadful disease of the organ is here represented; along with induration of the whole organ, ulceration had penetrated like a tunnel from the apex to the base; œdema of the glottis supervened. Sooner or later the absorbents are affected, becoming swollen, painful, and hard; and, as in malignant affections of other parts, the disposition and action is not limited to those in the immediate neighbourhood of the primary disease. The tongue is subject to simple induration, which is totally unconnected with malignant disposition, and subsides on improvement of the digestive organs; occasionally repeated leeching of the part accelerates the cure.

Enough has already been said about removing the local irritating cause, when such can be discovered; and the maxim, though most important, need not be formally repeated in regard to affections of the tongue. The simple ulcer heals under the usual applications to sores or mucous surfaces, the general health being at the same time attended to. For malignant disease, nothing but very early removal of the part can avail. But this is not always either advisable or practicable: the disease may have involved the organ too extensively, and the lymphatics may have too widely participated in the action. When the diseased part is small, and nothing contraindicates surgical interference, it may be removed by the bistoury; usually the bleeding is very slight, but if troublesome it is easily arrested by the cautery. When the disease is extensive, ligatures are to be employed. During the process a vulsellum is useful for grasping the morbid part, and securing the organ. The ligatures should be strong, and are introduced by needles in fixed handles. They may either be passed at once, or be preceded by finer ones, by which they are afterwards drawn through. The tongue is transfixed beyond the induration, and, if one ligature is sufficient, its noose is divided, and the parts tied separately, so as to include the mass. But frequently several ligatures are required, and their portions must be so disposed as not only to isolate all the indurated and ulcerated part, but also some of the neighbouring sound structure. They are tied firmly, to cut off vitality as completely as possible, and at once. Considerable swelling and profuse salivation follow, but gradually subside. In a short time fresh ligatures are passed through the old perforations, and drawn from time to time, till the part sloughs and drops away. This will not be found necessary if incisions are made betwixt the parts of the ligature in the first instance, so as to permit of their being tightly drawn. The swelling may be relieved by hot fomentations, and opiates mitigate the pain. The discharge is profuse and fetid. A weak solution of the chloride of soda, vinegar with honey, or a solution of the mel boracis, may be used as gargles. The healing of the wound is to be promoted by applications suited to the appearances which it may assume.

Inflammation of the Tongue occasionally occurs during certain eruptive diseases, and sometimes in consequence of accidental circumstances, as stings in the part from venomous insects; but it is not a common, affection, and is generally produced by the abuse of mercury. When that poison was used more freely than now, the disease in question was by no means rare. It was then customary to see patients who were made to spit some gallons in a day, for the cure of

a venereal affection, supposed or real, with their faces swollen, and their tongues protruding from their mouths, enormously enlarged. This consequence of the exhibition of mercury is more apt to occur in some constitutions than in others, and I have seen it produced in a violent form by the patient’s taking only two Plummer’s pills. In this case the patient, an old gentleman of broken constitution, had been filled brimful of mercury, over and over again, for one disease or another in warm climates.

The tongue swells rapidly, fills the mouth, and protrudes of a brown colour, from effused serum, with great enlargement of the papillæ. The patient is unable to speak, deglutition and respiration are much impeded, and thirst is excessive. In some instances the inflammation proceeds to suppuration, but the more general termination is resolution.

In the more mild cases, a cure will generally be procured by evacuating the bowels freely by means of saline purgatives, and by local abstraction of blood; the blood may be obtained either from the application of leeches, from opening several of the enlarged superficial veins, or from slight scarifications. Afterwards astringent lotions may be employed. But in more severe cases of glossitis, the tumour is productive of very great inconvenience to the patient, and is not unattended with danger; the difficulty in breathing may amount almost to suffocation, and in such the treatment must be active. Several free incisions are to be made longitudinally on the dorsum of the tongue; from these the effused fluids are evacuated, a considerable quantity of blood escapes, and consequently the tumour speedily subsides. Superficial incisions are not sufficient, and the practitioner should not shrink from cutting tolerably deep; for although the wounds may appear ghastly in the engorged and tumid condition of the organ, yet when the swelling subsides, and the tongue regains its usual bulk, their size, as in other situations, is so remarkably diminished, that they resemble trifling scarifications, and, in some instances, are almost imperceptible. Their extent and number must vary according to the size of the tumour, and the urgency of the concomitant symptoms. If such practice should fail in diminishing the swelling, and affording relief to the respiration, it may become necessary to perform tracheotomy. If the inflammation terminate in suppuration, the abscess must be treated on the same principles as those occurring in other parts of the body.

The tongue is also subject to gradual and permanent enlargement. A remarkable case of this nature occurred to me some years ago, and I shall here detail it shortly. The patient was a male, aged 19. The tongue was of a very large size, compressible and elastic, projected three or four inches from the lips, and completely filled the cavity of the mouth. It was of a dark brown hue, in some places livid; its surface was rough, at some points granulated, at others fissured, and at many traversed by large venous trunks. At the back part of the dorsum, the papillæ were much enlarged, granulated points were numerous, and several plexuses of dilated blood vessels ramified immediately beneath the investing membrane. There was occasional bleeding from an ulcerated fissure near the centre of the dorsum, and also from the lateral parts of the protruded portion: in the latter situation, several cicatrices were visible. Saliva flowed in a continuous stream from the apex of the tumour. The lower jaw, much separated from the upper, was elongated and unusually narrow; the teeth, particularly those in front, were placed at a distance from each other, were covered with tartar, and projected almost horizontally from the sockets. A depression was felt at the symphysis mentis, as if the two portions of the jaw were asunder, and the intervening space occupied by ligamentous matter. The enlargement was congenital, and the organ swelled rapidly, it was stated, every three months to a much larger size, and subsided gradually. The bleeding was most frequent and profuse when the swelling was greatest, and then too he suffered much pain in the part. Articulation was very indistinct, and could be understood only by those who were accustomed to be near him. He swallowed, and even masticated pretty freely. From the periodical enlargement and diminution, from the repeated hemorrhages, and from erectile tissue being visible on many parts of the surface, I considered the structure of the tumour to be in part similar to that of aneurism by anastomosis, and to be throughout extremely vascular. I therefore did not attempt removal by incision, but in the first instance intercepted its vascular supply by tying both lingual arteries. The tumour was not affected immediately on the application of the ligatures, but soon began to diminish gradually. Everything was proceeding favourably; but, on the seventh day, the tongue was attacked with inflammatory swelling, which advanced unsubdued, notwithstanding the most active treatment. Sloughing commenced at the apex, and appeared extending backwards; I then isolated the protruded portion of the organ by ligature, and thus removed it in three or four days. At that time he complained of no pain, and felt very comfortable. But his system became much disordered soon after; abscesses formed rapidly over both wrists and on the hands, unhealthy infiltration of

the cellular tissue took place at the root of the tongue, and amongst the deep muscles at the upper part of the neck, the parts became gangrenous, and he died. Dissection showed that the greater part of the tumour was composed of erectile tissue. A sketch of the lower jaw is here appended, in order to show the alteration in form, both at the symphysis and in the rami, which had resulted from the pressure of the organ and the necessarily constant open condition of the mouth.