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.
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.