THE TONGUE. 817 



aggravated by inflammatory changes induced by injury or exposure, and the tongue may assume 

 enormous dimensions and hang out of the mouth, giving the child an imbecile expression. The 

 treatment consists in excising a V-shaped portion and bringing the cut surfaces together with 

 deeply-placed silver sutures. Compression has been resorted to in some cases and with success, 

 but it is difficult to apply. Acute inflammation of the tongue, which may be caused by injury 

 and the introduction of some septic or irritating matter, is attended by great swelling from 

 infiltration of its connective tissue, which is in considerable quantity. This renders the patient 

 incapable of swallowing or speaking, and may seriously impede respiration. It may run on to 

 suppuration and the formation of an acute abscess. Chronic abscess, which has been mistaken 

 for cancer, may also occur in the substance of the tongue. 



The mucous membrane of the tongue may become chronically inflamed, and presents 

 different appearances in different stages of the disease, to which the terms leucoplakia, psoriasis, 

 and ichthyosis have been given. 



The tongue, being very vascular, is often the seat of nasvoid growths, and these have a tend- 

 ency to grow rapidly. 



The tongue is frequently the seat of ulceration, which may arise from many causes, as from 

 the irritation of jagged teeth, dyspepsia, tubercle, syphilis, and cancer. Of these the cancerous 

 ulcer is the most important, and probably also the most common. The variety is the squamous 

 epithelioma, which soon develops into an ulcer with an indurated base. It produces great pain, 

 which speedily extends to all parts supplied with sensation by the fifth nerve, especially to the 

 region of the ear. The pain in these cases is conducted to the ear and temporal region by the 

 lingual nerve, and from it to the other branches of the inferior maxillary nerve, especially the 

 auriculo-temporal. Possibly pain in the ear itself may be due to implication of the fibres of 

 the glosso-pharyngeal nerve, which by its tympanic branch is conducted to the tympanic 

 plexus. 



Cancer of the tonarue may necessitate removal of a part or the whole of the organ, and 

 many different methods have been adopted for its excision. It may be removed from the mouth 

 by the ecraseur or the scissors. Probably the better method is by the scissors, usually known 

 as Whitehead's method. The mouth is widely opened with a gag, the tongue transfixed with a 

 stout silk ligature, by which to hold and make traction on it and the reflection of mucous mem- 

 brane from the tongue to the jaw, and the insertion of the Genio-hyo-glossus first divided with 

 a pair of curved blunt scissors. The Palato-glossus is also divided. The tongue can now be 

 pulled well out of the mouth. The base of the tongue is cut through by a series of short snips, 

 each bleeding vessel being dealt with as soon as divided, until the situation of the ranine artery 

 is reached. The remaining undivided portion of tissue is to be seized with a pair of Wells's 

 forceps, the tongue removed, and the vessel secured. In the event of the ranine artery being 

 accidentally injured haemorrhage can be at once controlled by passing two fingers over the 

 dorsum of the tongue as far as the epiglottis and dragging the root of the tongue forcibly 

 forward. 



In cases where the disease is confined to one side of the tongue this operation may be 

 modified by splitting the tongue down the centre and removing only the affected half. In 

 cases where the submaxillary glands are involved Kocher's operation should be performed. 

 He removes the tongue from the neck, having performed a preliminary tracheotomy, by an incis- 

 ion from near the lobule of the ear, down the anterior border of the Sterno-mastoid to the level 

 of the great cornu of the hyoid bone, then forward to the body of the hyoid bone, and upward 

 to near the symphysis of the jaw. The lingual artery is now secured, and by a careful dissec- 

 tion the submaxillary lymphatic glands and the tongue removed, llegnoli advocated the removal 

 of the tongue by a semilunar incision in the submaxillary triangle along the line of the lower 

 jaw, and a vertical incision from the centre of the semilunar one backward to the hyoid bone. 

 Care must be taken not to carry the first incision too far backward, so as to wound the facial 

 arteries. The tongue is thus reached through the floor of the mouth, pulled out through the 

 external incision, and removed with the ecraseur or knife. The great objection to this operation 

 is that all the muscles which raise the hyoid bone and larynx are divided, and that therefore the 

 movements of deglutition and respiration are interfered with. 



Finally, where both sides of the floor of the mouth are involved in the disease, or where 

 very free access is required on account of the extension backward of the disease to the pillars 

 of the fauces and the tonsil, or where the lower jaw is involved, the operation recommended by 

 Syme must be performed. This is done by an incision through the central line of the lip, across 

 the chin, and down as far as the hyoid bone. The lower jaw is sawn through at the symphysis, 

 and the two halves of the bone forcibly separated from each other. The mucous membrane is 

 separated from the bone, and the Genio-hyo-glossi detached from the bone, and the Hyo-glossi 

 divided. The tongue is then drawn forward and removed close to its attachment to the hyoid 

 bone. Any glands which are enlarged can be removed, and if the bone is implicated in the 

 disease, it can also be removed by freeing it from the soft parts externally and internally, and 

 making a second section with the saw beyond the diseased part. 



Formerly many surgeons before removing the tongue performed a preliminary tracheotomy : 

 (1) to prevent blood entering the air-passages ; and (2) to allow the patient to breathe through 

 the tube and not inspire air which had passed over a sloughy wound, and which was loaded with 

 septic organisms and likely to induce septic pneumonia. By the judicious use of iodoform this 

 secondary evil may be obviated, and the preliminary tracheotomy is now usually dispensed 

 with. 



