Part 33

Before proceeding to operate, it should first be ascertained that the fissure is not of such extent as to prevent apposition of its edges, without great dragging of the parts; for, if the separation be wide, temporary approximation may perhaps be effected by ligatures strongly applied, but the apposition will not be complete or accurate throughout the whole fissure, and adhesion will not take place; the palate will be too much stretched, as to throw off the ligatures by ulceration at the transfixed points of its margins. The patient must be made aware of the nicety of the operation, of the responsibility that rests upon himself, and be exhorted to steadiness and patience. A single exclamation of pain may subvert the whole proceedings. He is seated opposite to a strong light, and made to open the mouth wide; if necessary, the jaws may be kept separate by a wooden wedge, placed so as not to interfere with the operator. The head is thrown back, and held steadily by an assistant. The operator depresses the tongue by the forefinger of the left hand. A long, narrow, sharp-pointed bistoury is passed through the velum, close to its attachment with the palatine plate, and about a sixteenth part of an inch from the edge of the fissure: it is then carried downwards to the point of the uvula, so as to detach a narrow slip from the whole edge. The same is done on the opposite side of the fissure during the proceeding, and to facilitate it the point of the uvula on each side may be held by long and properly pointed forceps. After allowing the patient a short rest, the coagula and mucus are cleaned away from the parts, to prepare for union. Long bent needles, in fixed handles, and armed, are passed through the pared edges on each side. On one side the ligature is thin, the opposite thick and strong; the former is attached to the loop of the latter, and withdrawn, leaving the strong ligature passed through both apertures; and by this the margins are gradually approximated, and retained by a firm knot. A second point of suture, and a third, if necessary, is applied in the same way, and as represented in the “Practical Surgery,” p. 558. Or a single short curved needle may be used. It is introduced by means of a portaiguille, with a long handle, and passed through, first from the outside of one edge, and then from the inside of the other. A ligature, either of thread or of pewter wire, can thus be conveyed at once; if the latter is employed, it is secured by twisting, and the ends cut off by pliers; the needle is attached to the wire by a female screw in its end. It is advisable to make incisions in the direction of the fissure on each side, through the mucous lining, in order to take off the strain from the stitches.

Afterwards, success depends on the patient. All attempts at articulation, and even deglutition, must be strictly forbidden for three, four, or five days.

Inflammation of the Soft Palate, Uvula, and Tonsils, requires in general little surgical treatment. Reiterated attacks may sometimes be traced to the progress of a wisdom-tooth, or to the presence of stumps in the posterior part of the upper or lower jaw. Perhaps the most common cause is sudden suppression of the discharges from the skin, and from the adjoining mucous surfaces, in consequence of exposure to cold. The affection is accompanied with pain and difficulty in swallowing, and frequent and difficult excretion of mucus. The secretion of the saliva is increased, the attempts to swallow it are frequent, and the inflamed parts being thereby put in motion, the pain is aggravated. From the inflammatory action extending along the Eustachian tube, the patient describes the pain as shooting towards the ear. The parts are red, and soon becomes swollen; in some cases to so great an extent, as completely to prevent deglutition; occasionally the breathing is impeded; but the inflammatory swelling must be very great indeed, to obstruct the openings into both mouth and nostrils, and thereby threaten suffocation. The voice is hoarse, croaking, and husky; and, when the swelling is considerable, the patient speaks only in a whisper. The internal swelling is often accompanied by an external painful tumour of the lymphatic glands, and the pain is much increased by external pressure. There is more or less concomitant fever, preceded by slight shivering.

Removal of the local cause, and mild antiphlogistic measures, are usually sufficient to effect resolution, and put a stop to the disease. General bleeding will seldom be required; blood is abstracted locally, either by scarifying the internal surface, or by applying leeches at the angle of the jaw. Fomentations afford much relief, and may be applied either externally, or internally by inhalation of the steam of water, or of water and vinegar. The greatest benefit is experienced from this remedy during the early stage, it being then employed either to promote salutary effusion and effect resolution, or at a later period to forward the secretion of purulent matter. At the same time, antimonials, purgatives, warm drinks, diaphoretics, and the pediluvium, are not to be neglected. In the relaxed state of the parts, after subsidence of the violent symptoms, stimulating and astringent gargles may be used with advantage.

But in neglected cases, or those originally violent, suppuration, sometimes extensive and dangerous, occurs in the cellular tissue, betwixt the pillars of the soft palate, or betwixt the layers of the velum. The swelling thereby formed may be so large as to impede the passage of air by both the mouth and nostrils. The mouth is opened with difficulty and pain; deglutition is seriously impeded, or altogether impracticable; the voice is weak and indistinct; and the countenance is swollen and discoloured. Life is endangered by the risk of the purulent matter bursting out suddenly during the painful and laborious efforts at respiration, and escaping into the air passages; fatal results have thus taken place, and to prevent such the abscess should be opened early. When the swelling is large, and attended with alarming symptoms, the matter is most conveniently evacuated by a flat and long trocar and canula. If the abscess be small, and the breathing not affected, there will be no danger in allowing the collection to burst spontaneously. Suppuration may also occur in the external glandular tumour, or in the surrounding cellular tissue. When sloughing to any extent takes place, it is in patients of an extremely debilitated habit of body, or when the affection is attendant on disease of a malignant character. Metastasis may take place to the larynx, to the trachea, or to the lungs, either spontaneously, or in consequence of repellent applications.

Chronic abscesses are occasionally met with in these parts, or behind the upper part of the pharynx, unconnected with disease of the subjacent bones. The matter must be evacuated as soon as its existence is ascertained. No great accumulation should be allowed to take place in any situation, far less in the immediate neighbourhood of important parts.

Scarification of the tonsils and surrounding membrane is seldom required. A lancet concealed in a canula, with a spiral spring to withdraw its point, is used for this purpose, and for opening abscesses; but dangerous and fatal results may ensue, and have actually followed such incisions of these parts. A sharp instrument directed outwards, made to penetrate either by the rash thrust of an ignorant and careless practitioner, or by a hurried movement of an unsteady patient, may reach the common trunk of the temporal and internal maxillary arteries, or even the internal carotid. The sheathed lancet may be useful in the hands of such as are not habituated to the use of instruments; but scarification of the parts and puncturing of abscesses can be effected safely by a straight, sharp-pointed bistoury, covered with a slip of lint to within three-quarters of an inch of its point. The patient’s head is steadied by an assistant, the point of the instrument directed backwards, not at all outwards, and its edge upwards so as to avoid wounding the tongue, which is also to be kept out of the way by the forefinger of the left hand.

New formations about the isthmus faucium are rarely met with. Small warty excrescences, and small pendulous, fatty, or polypous tumours, are occasionally seen. These, if productive of inconvenience, can be easily removed by cutting instruments.

Enlargements of the uvula and tonsils are common, impeding deglutition, and producing indistinct and burring articulation. If large, respiration is interfered with.

Elongation and Enlargement of the Uvula attends inflammatory attacks in the fauces, but may continue for a long time afterwards. The organ is increased in volume, both in length and in breadth, from interstitial deposition of new organised substance, and from unusual vascularity. The inconvenient size produces nausea and cough; it is even said that the tumour has, in some instances, got entangled in the rima glottidis, suffocating the patient, or at least giving rise to the most alarming symptoms. In some cases the elongation appears to have kept up cough and expectoration for months or years.

The parts may be touched with a bit of sponge, dipped in the tinct. muriatis ferri; but a more useful remedy is the powder of alum, applied either on a spatula, or by insufflation. Astringent decoctions, or solutions, are of little use. But in cases of large and long continued enlargements, the swelling cannot be expected to subside under such treatment, and recourse must be had to curtailment by cutting instruments, of which the best for this purpose are long blunt-pointed scissors and forceps, with hooked points. The patient is made to open his mouth wide; the surgeon then introduces the instruments into the month, and watching an opportunity when the uvula is nearly stationary, suddenly seizes and clips off a sufficient portion. This is followed by instant relief.

Frequently an œdematous swelling of the uvula, of a crystalline appearance, resembling a large grape, accompanies ulceration in the neighbourhood; puncturing of the part, and attention to the cause of the affection, are sufficient for the cure. When the bloodvessels of the uvula are in a state of chronic enlargement, scarification is also employed with advantage.

Chronic Enlargement of the Tonsils occasionally takes place in children, but generally in persons from eighteen to twenty-four years of age, or in such adults as are subject to irritations in the neighbourhood of the organs. A delicacy of constitution is supposed to be indicated by the affection. One or both tonsils may be enlarged, usually both. The surface of the tumour is irregular; the mucous follicles are enlarged, and often filled with sebaceous matter. The swellings in each side gradually approach each other, meet, and by narrowing the isthmus, seriously interfere with the functions of the parts. Little pain is felt, and that is dull, occasionally shooting through the ear. Respiration is at all times fettered, and during sleep noisy. Occasionally the swellings exceed their usual size, from some accidental excitement of the circulation. They may subside very considerably on the removal of the cause, or abatement of its operation, for there is nothing malignant in their nature. It is true, as I have seen, that the tonsils may be involved in malignant disease spreading from the neighbouring parts; but in the affection under consideration, no mark of malignancy appears, as far as I know. There is mere enlargement and opening out of the texture, without much, if any, change in structure or consistence; the part may be cut into without the risk of exciting unhealthy action, and the divided surface cicatrises readily.

Deobstruents, and iodine, as the most efficient, may be given, with perhaps some effect. In the adult, when the affection is troublesome, permanent, and of long duration, the exuberant matter must be removed, and this is accomplished either by ligature or by incision. The former method is the more difficult, tedious, painful, inconvenient, and dangerous. It is seldom that one ligature, with a simple noose, suffices; it is necessary to transfix the tumour, and, separating the portions of the ligature, to include the upper and under halves in distinct nooses. The latter method is the preferable. It is not requisite to cut out the whole tonsil, and there is risk in attempting such a measure, but that part only is removed which projects beyond the arches of the palate and the natural level of the gland. Long curved scissors may be employed, but the straight probe-pointed bistoury is more convenient; and this, to insure security, may be blunted to within an inch and a half of its point, or rolled so far in lint. To facilitate incision, the tumour is laid hold of by a sharp hook, or, what is better, by a vulsellum. Occasionally violent attempts at retching occur during the operation; but there is little pain or hemorrhage. The complicated machines invented for this purpose are worse than useless. The healing of the sore is hastened by fomentations and mild gargles, and by either stimulating or soothing applications, as circumstances require.

Excision of the tonsils is said to produce the bad effect of changing the pitch of the voice—taking from the high, and adding to the low notes. I have performed the operation, as above described, on professional vocalists, to remedy indistinctness of articulation and constant hoarseness, with the desired effect, and without altering either the pitch, quality, or compass of the voice. No doubt, unpleasant results might follow extensive incisions of the parts, as division of the anterior fold of the palate, and removal of the whole tonsil; but by paring off the prominent parts of the glands no risk is incurred.

Ulcers of the Palate, &c., are said to have arisen almost uniformly from contamination of the system, following sores on the genital organs. Now, at least, they seldom and scarcely ever occur from this cause, unless most execrable practice has been resorted to. Foul and extensive ulcers of the membrane of the mouth, of the tongue, of the gums, and of the folds of the palate, are common in those who have used mercury recently; and those whose constitutions have been saturated with mercury, or who have taken only alterative doses for a considerable time, are for a long while liable to ulcerations of these parts on exposure to moisture and cold—one set of sores healing, but others soon breaking out. It is, indeed, very rare to meet with sores in these situations that are not thus accounted for: certainly such as are by recurrence deep, extensive, and troublesome, are not seen unless in those who have suffered from mercurial medicines. Slight excoriations are not uncommon in individuals of the soundest and most untainted systems; but even in very young subjects, if the sore is of considerable size, and slow in healing, it will generally be found that some preparation of mercury, probably calomel, had been given previously, and perhaps without precaution and care. Calomel, as well as other forms of the mineral, is too often and too freely given, and without proper consideration; the ruin of many good constitutions is attributable to this cause, and to this cause alone. How long mercurial poisons continue to exercise a prejudicial influence on the constitution, is a question not easily determined. In many, its dominion is long and powerful. Frequently its effects are developed years after its exhibition, from accidental circumstances, such as change in the mode of living, derangement of the stomach and its appendages, exposure to inclement weather, change of climate, &c.

Sores form in various situations, between the pillars of the fauces—in the site of the tonsils—on the uvula, and by its side—on the posterior and anterior surfaces of the pendulous velum; sometimes the ulceration appears to have extended from the nostrils. Often the uvula is entirely lost; it is not long since I saw two uvulæ, in one day, as black as a bit of coal, surrounded by ulceration, and just about to drop away. Ulceration of the posterior surface of the velum is marked by dark redness, and swelling of the anterior. Sometimes it happens, that by deepening of the ulcers, the velum is perforated at one or more points, and the edge of the opening healing, a permanent deficiency remains. The whole of the soft palate may be destroyed, either by one extending ulceration, or by repeated attacks. When cicatrisation takes place, the posterior nares are narrowed, deformed, or even completely closed. Along with ulceration of the fauces, abscesses frequently form in the coverings of the hard palate; they are either the consequence or the cause of necrosis of part of the bone. Whatever their origin, more or less of the bone with which the matter is in contact, dies and separates; and thus openings are established between the cavities of the mouth and nostril. This is productive of great inconvenience, the patient speaks very indistinctly and, when taking food, a part of the more fluid ingesta returns by the nostrils. During the progress of the exfoliation, the breath is intolerably fetid.

Such is an outline of mercurial products in the mouth. Eruptions and ulcers on the surface of the body often accompany or follow them; and the patient gets into a bad state of health—becomes, in short, cachectic.

The state of the system must be ameliorated if possible; and chiefly by attention to the digestive organs. These may be improved by such medicines, as ipecacuan, taraxacum, gentian, rhubarb, scammony, aloes,—given in various doses and combinations, according to the circumstances of the individual case. The first two possess many of the good qualities of calomel, in regard to the biliary secretion, and leave no evils behind them. Sarsaparilla is a most important remedy, and the form of its exhibition should be varied when its effects begin to diminish. The different applications which may be made to the sores have been mentioned formerly; of them all, the nitrate of silver is the most generally useful, either in solution or in substance. It is used at intervals of two or three days, not to destroy living texture, but to diminish irritability and dispose to heal. If there be no great loss of substance, deficiency in the soft parts may be repaired by operation after the ulcerative disposition has ceased. In deficiency of the palate—during the progress of the ulceration in the bone and the parts investing it, and for some time after it has ceased—the inconvenience is lessened by filling the opening with crumb of bread softened, and made into a paste by kneading; this must be frequently renewed, otherwise it collects discharge, and becomes offensive. After cicatrization of the margins, and contraction of the opening, a metallic plate may be fitted in.

Ulcers of the Tongue.—Such as are not of a malignant kind are readily healed on improving the state of the digestive organs and general health. The state of the organ indicates that of the chylopoietic viscera, it enjoys intimate sympathy with the other parts of the alimentary canal, and why it should suffer from derangements of them is readily understood. The sores may be continued by local irritations, as by friction on encrusted tartar, or sharp or decayed portions of teeth, or by repeated application of heat, as in smoking. In consequence of long-continued irritation, like similar ulcers of the lips, they take on malignant action. The malignant ulcer generally occurs in patients 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.

Enlargement of the tongue occasionally takes place in young subjects, a sort of simple hypertrophy, which often proceeds to a very great extent. The increase goes on in a remarkable manner after the organ is extruded beyond the lips, so that the patient is incapable of covering it. Portions of the swelling of a V shape have been removed in such cases, and the edges of the wound put together. But by well managed and continued pressure the absorption of the swelling has been brought about, the organ has been reduced within the oral aperture, and a cure has then rapidly followed.

Division of the Frænum Linguæ is sometimes, though rarely, required. Division can be necessary only when the frænum is so short as to confine the point of the tongue, prevent free motion of the organ, and thereby cause indistinctness of articulation. Infants are often supposed by anxious mothers to have their tongues unduly confined, when no such malformation exists; in such circumstances, it is almost needless to observe that the part ought not to be interfered with. And even when there is confinement, division should not be had recourse to, unless the child is prevented from taking nourishment. The operative procedure is simple and safe. The tongue is raised towards the palate, either by a spitula or split card—or, what is better, by the fingers—and the frænum is cut across to a sufficient extent by blunt-pointed scissors.

Ranula is a swelling produced by accumulation in, and distention of, the extremity of the combined ducts of the sublingual and submaxillary glands. The extremity of the duct contracts, or is completely closed, and in consequence of the saliva and mucus (the one the secretion of the gland, the other of the duct) collect, distend the canal, and cause thickening of the parietes. Thereby a tumour is formed, which, in some instances, attains a very large size, displacing in some measure the neighbouring parts, and incommoding the tongue in particular. Indistinct utterance and impeded deglutition result.