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.
[Illustration]
_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.
[Illustration]
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.
[Illustration]
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.
The orifice of the duct, if discovered, is to be dilated gradually
by occasional introduction of variously sized probes. Often it is
necessary to make a small incision in the situation of the orifice, and
introduce a bit of gum-elastic bougie, by continuing the use of which
for some time, permanency of the opening may be obtained.
_Deposition of Earthy Matter_—principally phosphate of lime—not
unfrequently takes place in the extremity of the submaxillary and
sublingual ducts, and the concretion so formed is often of considerable
size; some are larger than an almond. The colour is either white or
yellowish, and the surface either smooth or roughened by nodules;
in all the calcareous matter is friable, and disposed in concentric
layers. They are of the same nature as the earthy deposits, called
tartar, which form on those teeth opposite to the extremities of the
salivary ducts. The foreign body produces uneasiness in the mouth,
swelling, and indistinctness of speech; occasionally painful swelling
of the salivary gland and surrounding parts takes place. Concretions
also form, though very rarely, in the extremity of the parotid duct,
and are attended with like inconvenience; of this I have seen only two
cases.
The foreign body is easily removed; an incision is made through the
membrane of the mouth, and the concretion dislodged by forceps, a
scoop, or the fingers. The saliva regains its course, and irritation
subsides. Sometimes the foreign body is exposed by ulceration, and
might ultimately escape from its bed spontaneously.
[Illustration]
A figure of a salivary calculus of considerable size is here given.
When the concretion is small, its extraction is not so easily
accomplished as might be supposed. It is apt to slip back out of reach,
so that it cannot be seized, brought forward and extracted either by
scoops or forceps. The flow of saliva must be promoted by giving the
patient something to masticate; the probability is, that the foreign
body will then be presented, and perhaps expelled, if the opening of
the duct has been previously dilated. A young lady was brought to me
lately suffering great uneasiness from the presence of a concretion,
not larger than a millet-seed. She complained of great pain under the
jaw on seeing anything savoury, that, as the vulgar phrase is, made her
mouth water. Various unsuccessful attempts had been made to remove it.
A small incision of the surface of the duct was made, but the foreign
body eluded the grasp of the forceps, and completely disappeared. The
patient was given a bit of bread to chew, and almost immediately the
concretion was expelled.
_Tumours_, unconnected with the salivary ducts, occasionally form
in the loose cellular tissue under the tongue. They may be either
sarcomatous or encysted; the former are rare. I have removed several
solid tumours, principally adipose, from this situation. They were
loosely connected, and taken away without almost any dissection; indeed
they were lifted out with the fingers, after division of the membrane
of the mouth and of the cellular cyst which surrounded them. One was
as large as an orange, and of a flattened form. The tongue had been
displaced by the swelling, and articulation, deglutition, and breathing
impeded. The patient, an old lady, had a good recovery. The case had
been by some mistaken for ranula; and I mention this circumstance, lest
others may reckon more on the situation of a swelling, than on its feel
and other external characters. A sketch of the tumour is given at page
137.
Encysted tumours below the tongue are common. The cysts are generally
thin and adherent, the contents albuminous and glairy. They attain a
large size, and prove very inconvenient. Occasionally the cysts are
thick and more loosely attached; such usually contain atheromatous
matter. I removed one uncommonly large, from the inner surface of which
numerous hairs were growing.
Encysted tumours here can seldom be removed by dissection; the depth of
their situation, their firm connexion, the awkward situation in which
the patient is necessarily placed, and the risk of hemorrhage, forbid
the surgeon from attempting regular extirpation. A more simple and
equally effectual procedure is as follows:—The membrane of the mouth
and the cyst are divided by the point of a bistoury; and if the tumour
be large, and the distention great, an oval portion of the parietes
may be cut out. The contents are thus evacuated. The bleeding is
allowed to cease, and the cavity having been wiped out clean, a stick
of caustic potass is applied to the surface, so as to annihilate the
cyst effectually. This I believe to be the only radical and safe mode
of removal; after any other, the tumour is certain to be reproduced.
It has been recommended to pass a seton, so as to excite inflammatory
action, and lead to obliteration of the cyst. I have made trial of this
practice, but most dangerous swelling ensued, the mouth was rapidly
filled, and the system alarmingly shaken; after all the disease was not
eradicated.
Tumours beneath the tongue, however originating, occasionally inflame,
and become the seat of unhealthy abscess. A large and painful swelling
forms, and projects under the chin. The matter gradually approaches
the surface, and perhaps evacuates itself imperfectly into the mouth,
or the integuments give way, and afford an external issue. In such
cases, an early incision from the mouth may prevent the internal
mischief, and the disfiguration of the countenance which would
otherwise ensue may, in short, limit the suppuration; at a later period
a free opening requires to be made below the chin, in the mesial
line, and in the direction of the muscular fibres. A ready drain is
thus obtained for the matter, and the cavity of the abscess gradually
contracts.
_Tumours of the Gums_ are usually hard, and not inclined to increase
rapidly. They are of the same consistence as the parts to which they
are attached, and grow either inwardly, outwardly, or both. They
surround one or more teeth, which at last become loose, the alveolar
processes then soften, and form part of the swelling.
These may degenerate, and grow rapidly, or the tumour may be soft
(tumor mali moris) from the first. The attention of the patient is
directed to the part by the occurrence of discharge from about the
teeth, which loosen one after another. A soft tumour arises from the
sockets after either extrusion or extraction of the teeth, it grows
rapidly, and involves more and more of the gums and alveolar processes.
Angry ulceration attacks the prominent parts of the swelling; the
bone is softened to a considerable extent around; the discharge is
thin, bloody, and profuse. Ultimately the lymphatics become affected,
neighbouring parts are contaminated, malignant action acquires a firm
footing, and extends, the patient becomes hectic, and dies.