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.