Manual of Surgery Volume II Part 55

#Tuberculous arthritis# is rare, and is usually secondary to disease of the mandible, the temporal bone, or the middle ear. It leads to destruction of the joint and ankylosis. It is treated by incision and sc.r.a.ping, or by excision of the condyle.

#Arthritis deformans# is a comparatively common affection, and is generally bilateral. In the earlier stages the condyle is usually hypertrophied and distorted, and the glenoid cavity is correspondingly broadened and flattened, and in time may be filled up by new bone.

Osteophytic outgrowths form around the joint and lead to fixation or locking. The enlarged condyle may be felt in front of the ear, and there is pain and cracking on movement; the pain is worst at night and in wet weather. The jaw is usually depressed and the chin protruded.

The disease runs a chronic course, with occasional acute exacerbations. Excision of the condyle may be advisable when non-operative measures have failed to give relief. In the later stages, the condyle, together with the meniscus, may be worn away and completely disappear.

#Closure or Fixation of the Mandible.#--_Temporary fixation_ is due to spasmodic contraction of the muscles of mastication, particularly the ma.s.seter. This may be symptomatic of some inflammatory condition in the vicinity, such as a pyogenic affection of the lower jaw--for example, that a.s.sociated with a carious root or an unerupted wisdom tooth, or with parot.i.tis or tonsillitis. In such cases the spasm pa.s.ses off on the removal of the cause. It is occasionally a manifestation of hysteria. The administration of a general anaesthetic and the introduction of a wedge or separator is usually necessary to confirm the diagnosis and, it may be, to permit of operative measures, such as the extraction of a wisdom tooth.

Muscular fixation may be due to rheumatic or syphilitic myositis, and this is sometimes followed by fibroid degeneration of the muscles, rendering the fixation permanent.

_Permanent fixation_ may be due to a variety of causes. Fibroid degeneration of muscles following myositis has already been mentioned.

Much more frequently it results from cicatricial contraction of the soft parts of the face or mouth following such conditions as cancrum oris, ulceration, or burns. Fixation following upon prolonged immobilisation after fracture or dislocation, or any of the forms of arthritis or suppurative or tuberculous disease of the adjacent portions of the mandible, is also met with. The ankylosis may be fibrous or osseous, and may be intra- or extra-articular.

The _clinical features_ vary with the degree of separation of the jaws. There is always some deformity, and more or less interference with mastication and speech. The patient usually feeds himself by pushing small portions of bread or meat with the fingers through some gap between the badly opposed and badly formed and preserved teeth. As the patient is unable to keep the mouth clean, particles of food lodge and decompose there, causing irritation of the mucous membrane, caries of the teeth, and ftor of the saliva and breath. When osseous ankylosis occurs in childhood, it leads to _arrest of development of the mandible_, which is small and markedly receding, so that the teeth do not oppose those of the maxilla (Fig. 256).

[Ill.u.s.tration: FIG. 256.--Defective development of Mandible from fixation of jaw due to tuberculous osteomyelitis in infancy.]

_Treatment._--When the cause of the fixation is in the joint itself, the best treatment is to resect one or both condyles.

When the fixation is due to cicatricial contraction of the soft parts, mobility is best restored by forming an artificial joint well in front of the cicatricial tissue, as suggested by Esmarch.

CHAPTER XXII

THE TONGUE

Surgical Anatomy--Wounds--Dental ulcer--Inflammatory affections: _Acute parenchymatous glossitis and hemi-glossitis_; _Mercurial glossitis_; _Chronic superficial glossitis_; _Leucoplakia_; _Smoker's patch_--_Tuberculous disease_; _Syphilitic affections_; _Sclerosing glossitis_; _Gummas_; _Ulcers and fissures_--Tumours: _Carcinoma_; _Sarcoma_; _Innocent tumours_; _Cysts_--Thyreo-glossal tumours and cysts--Malformations: _Absence_; _bifid tongue_; _Tongue-tie_; _Excessive length of frenum_; _Macroglossia_; _Atrophy_--Nervous affections.

#Surgical Anatomy.#--The tongue is composed of interlaced, striped muscle fibres, partly consisting of the terminations of the extrinsic muscles, and partly of the intrinsic muscles. A median fibrous septum divides it into two lateral halves so completely that but little communication takes place between the blood vessels and lymphatics of the two sides. It is covered by stratified squamous epithelium. For practical purposes it is described as consisting of an _anterior_ or _oral_ part, and a _posterior_ or _pharyngeal_ part.

The _oral part_, which includes the anterior two-thirds of the organ, is mobile, and the epithelium on its dorsal aspect is modified so as to form several varieties of papillae. A slight median depression is recognisable on the dorsum as far back as the vallate (circ.u.mvallate) papillae, which mark the boundary between the oral and pharyngeal parts. A double fold of mucous membrane--the _frenum_--connects the under aspect of the tip with the floor of the mouth and the mandible.

On each side of the frenum, under the mucous membrane of the tip, are mucous glands--_apical glands_--in which cysts sometimes form. On the lateral border of the tongue, just in front of the anterior palatine arch, are several vertical folds of mucous membrane--the _folia linguae_, or _foliate papillae_.

The _pharyngeal_ part, or base of the tongue, forms the anterior wall of the pharynx, and is attached to the hyoid bone. Its mucous membrane is devoid of papillae, but contains numerous lymphoid follicles--the _lingual tonsil_. The _foramen caec.u.m_ lies just behind the apex of the vallate papillae in the middle line.

The chief artery, the _lingual_, a branch of the external carotid, pa.s.ses forward beneath the hyoglossus muscle, and is continued to the apex as the ranine, lying nearer the under than the upper aspect of the tongue. The pharyngeal part is supplied by the dorsalis linguae branch. The blood is returned to the internal jugular by the ranine vein, which can be seen under the mucous membrane on the inferior aspect near the frenum, and by the venae comites of the lingual artery and its branches.

The _hypoglossal_ is the motor nerve of the tongue. The _lingual_ branch of the mandibular (inferior maxillary) supplies the anterior two-thirds with common sensation. It is accompanied by the _chorda tympani_ branch of the facial, which probably carries the taste fibres. The _glosso-pharyngeal_ supplies the posterior third of the tongue with both common and gustatory sensation.

The _lymph vessels_ of the anterior two-thirds of the tongue drain into the submental and submaxillary glands, and these in turn into the deep cervical group which accompany the internal jugular vein. The vessels of the base converge into several large trunks which pa.s.s out behind the tonsils and drain directly into the deep cervical glands.

One of these, which lies in the angle between the internal jugular and common facial veins, is frequently infected in cancer of the tongue.

#Wounds# are commonly produced by the teeth, as, for instance, when a child falls on the chin with the tongue protruded, or when an epileptic bites his tongue during a fit. Less frequently a foreign body, such as a pipe-stem, a bullet, or a displaced tooth, is driven into the tongue. The immediate risk is haemorrhage, particularly when the posterior part of the tongue is implicated and the wound penetrates deeply. Of the later complications, infections and secondary haemorrhage are the most serious, and they are most liable to occur when a foreign body is embedded in the tongue.

_Treatment._--In superficial wounds near the tip the oozing is efficiently arrested by sutures, but in deeper wounds a ligature must be applied to the bleeding vessel. Secondary haemorrhage is much more difficult to arrest on account of the friable state of the tissues, and it may be necessary to ligate the lingual or even the external carotid in the neck.

To prevent infective complications any foreign body must be removed and an antiseptic mouth-wash regularly employed.

Cases have been recorded in which such a foreign body as a bullet, a needle, or a piece of a pipe-stem, has remained embedded in the substance of the tongue for a long period, and caused a firm, indolent swelling liable to be mistaken for a new growth.

#Dental Ulcer.#--The continuous friction of a jagged tooth, or of an ill-fitting dental plate, is liable to cause swelling and excoriation of the side of the tongue. A painful superficial ulcer forms, and if the irritation continues and infection occurs, the surrounding parts become indurated, the ulcer a.s.sumes a crater-like appearance, not unlike that of a commencing epithelioma. If such an ulcer does not promptly heal on the removal of the irritant, a portion of the margin should be removed and submitted to microscopic examination to make sure that it is not cancerous.

#Inflammatory Affections.#--_Acute Parenchymatous Glossitis_ is usually due to the action of streptococci. Although it affects mainly the mucous membrane and submucous tissue, it causes a diffuse dematous swelling of the whole organ, and this may extend to the ary-epiglottic folds and give rise to dema of the glottis. As a rule it does not go on to suppuration.

The onset is sudden, and is marked by pain and stiffness of the tongue, particularly when the patient attempts to masticate or to speak. The tongue rapidly swells, and in the course of twenty-four or forty-eight hours may fill the mouth and protrude beyond the teeth.

There is profuse salivation, and in addition to difficulty in swallowing and speaking there may be considerable interference with respiration. The salivary and lymph glands in the submaxillary s.p.a.ce are enlarged and tender. The symptoms begin to subside in three or four days, unless suppuration occurs.

The _treatment_ consists in administering a sharp purge and employing a mouth-wash; leeches may be applied to the submaxillary region with benefit. When the swelling is excessive, it may be necessary to make longitudinal incisions into the substance of the tongue, and dyspna may call for laryngotomy. If an abscess forms it must be opened.

A similar condition has been met with in patients who have contracted the "_foot and mouth disease_" of cattle. Vesicles form on the mucous membrane, and after bursting, ulcerate, and a mixed infection with streptococci occurs, leading to diffuse dema. Portions of the tongue may become gangrenous, and the infection may spread to the tissues of the neck and set up one form of angina Ludovici. The condition is usually fatal.

_Acute Hemi-glossitis._--An acute transitory swelling, confined to one half of the tongue, in the distribution of the lingual nerve, is occasionally met with. It is attended with great pain and high temperature, and is believed to be a.n.a.logous to herpes zoster (Guterbock).

_Mercurial Glossitis_ may accompany mercurial stomat.i.tis (p. 496).

_Chronic Superficial Glossitis._--Several forms of chronic superficial glossitis are met with. The most important, as it is frequently followed by the development of epithelioma, is that known as _leucoplakia_ or _leuc.o.keratosis_.

The tongue is studded over with white patches, which result from overgrowth and cornification of the surface epithelium, whereby it becomes thickened and raised above the surface, and at the same time there is small-celled infiltration of the submucous tissue. The patches are irregularly lozenge-shaped, and when crowded together they present the appearance of a mosaic (Fig. 257). Similar patches are often present on the mucous membrane lining the cheek.

[Ill.u.s.tration: FIG. 257.--Leucoplakia of the Tongue.]

The disease is met with almost invariably in men between the ages of forty and fifty. Syphilis appears to be a predisposing factor, and any form of irritation--for example, the chewing or smoking of tobacco, the drinking of raw spirits, friction by a rough tooth or tooth-plate--plays an important part in inducing or in aggravating the condition.

The milder forms give rise to no discomfort, but when the condition is advanced the patient complains of dryness and hardness of the tongue, with impairment of the sense of taste and persistent thirst. When cracks, fissures, or warts develop, there is pain on chewing or speaking, or on taking hot or irritating food. The glands below the jaw may be enlarged.

The disease is most intractable and persistent, and even after disappearing for a time is liable to recur. After a variable number of years epithelioma is p.r.o.ne to develop, usually in one or other of the fissures which accompany the condition.

The _treatment_ consists in removing all sources of irritation, particularly smoking, and in employing mouth-washes. Butlin recommends antiseptic ointments applied before going to bed. In some cases painting the patches with chromic acid (10 grains to the ounce) or lactic acid (20 per cent.) is useful in removing the excess of epithelium, but stronger caustics are to be avoided. Const.i.tutional treatment is of little use even when the patient has suffered from syphilis. The best results have been attained by the use of radium.

The "_smoker's patch_" consists of a small oval area on the front of the tongue from which the papillae have disappeared. It is slightly raised, smooth and red, and may be covered with a yellowish-brown or yellowish-white crust. It causes no discomfort unless the crust is removed, when a raw, sensitive surface is exposed. The condition is liable to spread over the tongue if the patient persists in smoking.

It may eventually a.s.sume the characters of leucoplakia. The _treatment_ consists in stopping the use of tobacco, and painting the patches with chromic acid, tannic acid, or alum, and employing a chlorate of potash mouth-wash.

#Tuberculous Disease.#--The tongue is rarely the primary seat of tuberculosis. The majority of cases occur in adult males, who suffer from advanced pulmonary or laryngeal phthisis, the tongue being infected by bacilli from the sputum or through the blood stream. In other cases the infection is due to direct spread of lupus from the face or nose.

The condition may begin as a firm, painless lump, seldom larger than a hazel-nut, on one side of the tongue, or near its tip. At first the swelling is covered by epithelium; in time caseation takes place, the epithelium gives way, and an open sore is formed.

The _tuberculous ulcer_ is the form most frequently met with. The surface of the ulcer is uneven, pale and flabby, and is covered with a yellowish-grey discharge, with here and there feeble granulations showing through. The edges are shreddy, sinuous in outline, and there is little or no induration. The surrounding parts are slightly swollen, and may be studded with small tuberculous foci. The ulcer may be quite superficial, or it may extend into the muscular substance, and the tip of the tongue may be completely eaten away so that it looks as if it had been cut off with a knife. As the disease advances there is severe pain and usually profuse salivation. The submaxillary glands may be, but are not always, enlarged. The ulcer may heal, but tends to break down again.

Unless there is advanced pulmonary disease or other contraindication to operation, the ulcer should be excised under local anaesthesia. Care must be taken to avoid reinfecting the raw surface. When excision is impracticable, it is only possible to palliate the symptoms by dusting with orthoform, or applying local anaesthetics, and by attending to the hygiene of the mouth and removing all sources of irritation.

#Syphilitic Affections.#--A _primary lesion_ on the tongue is accompanied by marked enlargement and tenderness of the submaxillary lymph glands on one or on both sides. It is most common in men, infection usually taking place through the medium of tobacco pipes, or implements such as the blow-pipes of gla.s.s-blowers.

During the _secondary stage_--particularly in the later periods--mucous patches and ulcers are common, and they may a.s.sume a condylomatous or warty appearance.

The _tertiary_ manifestations in the tongue are sclerosing glossitis, gummas, and gummatous ulcers.