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 (circumvallate)
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 caecum_ lies just behind the apex of the
vallate papillae in the middle line.
The chief artery, the _lingual_, a branch of the external carotid,
passes 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 pass 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 assumes 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
oedematous swelling of the whole organ, and this may extend to the
ary-epiglottic folds and give rise to oedema 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 space
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 dyspnoea
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 oedema. 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 analogous to herpes zoster
(Gueterbock).
_Mercurial Glossitis_ may accompany mercurial stomatitis (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 _leucokeratosis_.
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.
[Illustration: 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 prone 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. Constitutional
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 assume 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 glass-blowers.
During the _secondary stage_--particularly in the later
periods--mucous patches and ulcers are common, and they may assume a
condylomatous or warty appearance.
The _tertiary_ manifestations in the tongue are sclerosing glossitis,
gummas, and gummatous ulcers.
_Sclerosing glossitis_ is the term applied by Fournier to a condition
in which there is an abundant new formation of granulation tissue in
the substance of the tongue, leading to the appearance of tuberous
masses on the dorsum. These tend to be oval in outline, are elevated
above the normal mucous membrane, and present a dull red mammilated or
lobulated surface, comparable to the surface of a cirrhotic liver.
They are firm, elastic, and insensitive.
A _gumma_ is usually situated on the dorsum and more often towards the
centre than at the edges. As it seldom implicates the floor of the
mouth or the base of the tongue, the tongue can usually be protruded
freely. It forms an indolent swelling, which tends to break down
slowly and to ulcerate. So long as it remains unbroken it does not
cause pain, and there is no enlargement of the adjacent lymph glands.
Two forms are met with--the superficial, and the deep or
parenchymatous.
A _superficial_ gumma appears as a small hard nodule under the mucous
membrane, varying in size from a pin's head to a pea. The mucous
membrane over it is redder than normal, and in the early stages
retains its papillae but later becomes smooth. It tends to break down
early, forming a superficial ulcer. Superficial gummas are often
multiple.
The _deep_ or parenchymatous form varies in size from a hazel-nut to a
walnut, and feels like a hard body in the substance of the tongue.
The mucous membrane over the swelling is of normal colour, but is
usually devoid of papillae. The gumma may remain for months unchanged,
or may approach the surface, soften, and break down, leaving a deep,
ragged ulcer.
_Syphilitic ulcers and fissures_ are nearly always due to the
softening and breaking down of gummas. The ulcers have seldom the
typically rounded or serpiginous outline of gummatous ulcers on other
parts of the body. The base is ragged and unhealthy, and on it a
yellowish-grey slough resembling wash-leather may be seen. The edges
are steep, ragged, and often undermined, and the surrounding parts
thickened and indurated. The neighbouring glands are not usually
enlarged. The ulcer is extremely painful when irritated by food, hot
fluids, or spirits. If untreated, the sore may remain indolent and for
months show no sign either of spreading or healing, but at any time it
may become the seat of cancer.
Syphilitic fissures are met with as long, narrow, deep clefts, or as
stellate or sinous cracks in the substance of the tongue. After the
healing of these ulcers and fissures permanent furrows and depressed
scars remain.
_Treatment._--The tertiary manifestations of syphilis in the tongue
are treated on the same lines as other tertiary lesions. Locally, the
use of mouth-washes, such as chlorate of potash or black wash diluted
with lime-water, the insufflation of powdered iodoform and borax with
a small quantity of morphin, or the application of mercurial ointment
is useful. The sore must be thoroughly cleansed before these remedies
are applied.
NEW GROWTHS
#Carcinoma# is by far the most common form of new growth met with in
the tongue, and it is almost invariably a squamous epithelioma.
Epithelioma generally occurs between the ages of forty and sixty, and
attacks males oftener than females, in the proportion of about six to
one. Its development is favoured by any long-continued irritation,
such as the rubbing of the tongue against a carious tooth, an
ill-fitting tooth-plate, or the rough end of a short clay pipe,
particularly when such irritation leads to the formation of an ulcer.
Chronic superficial glossitis associated with leucoplakia, and
syphilitic fissures, ulcers, or scars, also act as predisposing
factors. The repeated application of strong caustics to chronic
inflammatory conditions is, according to Butlin, a determining cause
of cancer. The degree of malignancy appears to vary in different
cases, and is probably lowest when the disease originates in a patch
of leucoplakia or other pre-cancerous lesion.
The disease is usually situated in the anterior half of the tongue,
and more commonly on the edge than on the dorsum. It may begin as an
excoriation, ulcer, or fissure, or as a warty growth, particularly in
association with a patch of leucoplakia. In all cases ulceration
begins early, and the base of the ulcer and the surrounding parts
become indurated. The lymph glands are, as a rule, early infected.
_Clinical Features._--The clinical appearances vary widely. Sometimes
the surface presents a warty growth; sometimes it is excavated,
forming a deep ulcer with raised nodular edges; in other cases the
ulcer is smooth, and its edges even and rounded. Extreme hardness of
the edges and base of the ulcer is always a characteristic feature.
The tongue tends to become fixed, especially when the disease spreads
to the floor of the mouth, so that it cannot be protruded, and the
restriction of its movement produces a characteristic interference
with articulation, certain words being slurred, and when the fixation
is extreme it may interfere with mastication and swallowing. The
patient complains of a constant gnawing pain in the tongue, and of
severe pain shooting along the branches of the trigeminal nerve, and
especially towards the ear. In the advanced stages there is salivation
and foetor of the breath.
When the disease is situated on the edge of the tongue it tends to
spread to the floor of the mouth and the muco-periosteum of the
mandible. If situated far back on the dorsum, it spreads on to the
epiglottis, the pillars of the fauces, and the tonsil.
The neighbouring lymph glands--particularly those under the jaw and
along the line of the carotid vessels--soon become infected and are
palpable. The submaxillary and sublingual salivary glands are also
liable to be affected. The enlarged cervical glands later undergo
softening, or suppurate and burst on the skin surface, forming
fungating ulcers. Metastasis to the liver, lungs, and other viscera is
exceptional. If the disease is allowed to run its course, the patient
usually dies in from twelve to eighteen months from repeated small
haemorrhages, toxin absorption, or septic broncho-pneumonia.
_Differential Diagnosis._--Cancer of the tongue has to be diagnosed
from syphilitic and tuberculous affections, from papilloma, and from
simple ulcer and fissure. It is to be borne in mind that any of these
conditions may take on malignant characters and develop into
epithelioma. The microscopic examination of a portion of the growth
removed under local anaesthesia from the base of the ulcer at some
distance from its epithelial core is often the only certain means of
establishing the diagnosis, and should be had recourse to as early as
possible. When there is still doubt as to the nature of the growth, it
should be treated as if it were cancerous.
An unbroken gumma is liable to be confused only with the uncommon form
of epithelioma which begins as a nodule under the mucous membrane.
Gumma, however, are often multiple, and the tongue shows old scars or
other evidence of syphilis.
Gummatous ulcers are usually situated on the dorsum, are frequently
multiple, and have sloughy, undermined edges; the surrounding parts,
although indurated, are not so densely hard as in cancer; there is not
necessarily any involvement of lymph glands. The cancerous ulcer is
usually single and situated on the margin of the tongue; its edges are
hard, raised, and nodular; and the glands are usually enlarged and
hard. Little reliance is to be placed on the therapeutic effects of
anti-syphilitic drugs in the differential diagnosis, as they are often
inconclusive, and their use results in loss of time.
Tuberculous ulcers usually occur in association with other and
unmistakable evidences of tuberculosis. A papilloma, when sessile, may
simulate cancer; these tumours show a marked tendency to become
malignant. Simple ulcers and fissures are usually recognised by the
history of the condition, the absence of induration and of glandular
involvement, and by the fact that they heal quickly on removal of the
cause.
_Treatment._--The only treatment that offers any hope of cure is free
removal of the disease, and experience has proved that unless this is
done early the prospect of the cure being a radical one is remote. Not
only must the segment of the tongue on which the growth is situated be
widely excised, but all the lymphatic connections must also be removed
whether the glands are palpably enlarged or not.
The chief risk after operation is pneumonia resulting from the
inhaling of blood and products of infection: hence the importance of
rendering the mouth as dry and as sweet as possible before operation,
special attention being paid to the teeth, and precautions being taken
at the operation to prevent the passage of blood down the trachea. The
patient is usually able to be out of bed on the second or third day,
and is well in a fortnight or three weeks. The operation, even when
followed by recurrence, usually prolongs life by six or eight months,
and renders the patient more comfortable by removing the foul ulcer
from the mouth. The speech, although impaired by the removal of
one-half or even more of the tongue, is distinct enough for ordinary
purposes. When recurrence takes place it is usually in the glands, and
may be attended with great suffering.
_Treatment of Inoperable Cases._--The mouth must be kept as sweet as
possible. The pain may be relieved to some extent by cocain or
orthoform, but as a rule the free administration of morphin is called
for. Pain shooting up to the ear may be relieved by resection of the
lingual nerve, or the injection of alcohol into its substance. If
haemorrhage takes place from the ulcerated surface and cannot be
controlled by adrenalin, or other local styptics, it may be necessary
to ligate the lingual, or even the external carotid artery.
Interference with respiration may necessitate tracheotomy. When the
patient has difficulty in taking food, recourse should be had to the
use of the stomach-tube or to gastrostomy. The use of radium or of the
X-rays appears to have a restraining influence on the disease in the
glands, but has not proved curative.
#Sarcoma# of the tongue is rare, and is sometimes met with in
children. The round-cell type is the most common; it grows rapidly,
and tends to ulcerate and fungate, pain becoming severe when the
growth has broken down. The diagnosis is always difficult, and is
seldom made until a portion of the growth has been removed and
examined microscopically. The more slowly growing forms, if removed
before ulceration has taken place, show little tendency to recur, but
those which grow rapidly and break down, not only recur locally, but
are liable to give rise to metastases. The treatment is the same as
for cancer; the use of radium is more likely to be beneficial than in
epithelioma.
#Innocent Tumour and Cysts.#--_Lipoma_, _fibroma_, and various forms
of _angioma_ (Fig. 258) are occasionally met with. They are all of
slow growth, and give rise to inconvenience chiefly by their bulk, and
should be removed.
[Illustration: FIG. 258.--Papillomatous Angioma of left side of tongue
in a woman aged 26.]
_Papilloma_ may occur on any part of the tongue, and at any age. It
may be single or multiple, pedunculated or sessile, and is liable to
become malignant, especially when associated with leucoplakia. It
should be freely removed by excising a wedge-shaped portion of the
tongue.
_Dermoid_ cyst is met with beneath the tongue, lying in the middle
line, between the genio-glossi (genio-hyoglossi), and on the upper
surface of the mylo-hyoid muscles. It may be noticed soon after
birth, or may only attract attention during adult life. The cyst
usually projects under the chin, forming a soft swelling of putty-like
consistence, which varies in size from a pigeon's to a turkey's egg
(Fig. 259). When it bulges towards the mouth it is liable to be
mistaken for a retention cyst of one of the salivary glands. It is
distinguished by its medial position, its yellow colour, and its
opacity, the retention cyst being to one side of the middle line,
purplish in colour, translucent and fluctuating. The cyst should be
dissected out, either from the mouth or from under the chin, according
to circumstances.
[Illustration: FIG. 259.--Dermoid Cyst in middle line of neck.
(Mr. J. W. Struthers' case.)]
A _sebaceous cyst_ may reach such dimensions as to simulate a dermoid
or thyreo-glossal cyst.
_Hydatid and cysticercus cysts_ have also been met with in the tongue.
#Thyreo-glossal Tumours and Cysts.#--Tumours may develop in the
embryonic tract which passes from the isthmus of the thyreoid gland
to the foramen caecum at the base of the tongue--the thyreo-glossal
tract of His. They have the same structure as the thyreoid gland, and
occupy the dorsum of the tongue, extending from the foramen caecum
backwards towards the epiglottis, in some cases attaining considerable
size. They are of a bluish-brown or dark red colour, and are liable to
repeated attacks of haemorrhage. These tumours sometimes become cystic,
the cysts being lined with ciliated epithelium and containing colloid
material. Bleeding may take place into a cyst, causing it to become
suddenly enlarged, or the cyst may burst and the blood escape into the
mouth. These variations in size and repeated attacks of bleeding help
to distinguish thyreo-glossal cysts from other swellings of the
tongue. Treatment is only called for when the swelling causes
interference with speech or swallowing; it consists in removing the
tumour by dissection.
When the lower end of the tract becomes cystic it forms a swelling in
the neck (p. 583).
#Malformations.#--Complete or partial _absence_ of the tongue is
exceedingly rare.
Occasionally the fore part of the tongue is _bifid_. The function of
the organ is not interfered with, and the operation of paring and
suturing the two halves is only called for on account of the
disfigurement.
_Congenital tongue-tie_ is a condition in which the tip of the tongue
is bound down to the floor of the mouth by an abnormally short and
narrow frenum, or by folds of mucous membrane on each side of the
frenum, so that the tongue cannot be protruded. Although this
deformity is rare, it is common for parents to blame an imaginary
tongue-tie when a child is slow in learning to speak, or when he
speaks indistinctly or stammers, and the doctor is frequently
requested to divide the frenum under such circumstances. In the vast
majority of cases nothing is found to be wrong with the frenum. In the
rare cases of true tongue-tie the edges of the shortened bands should
be snipped with scissors close behind the incisor teeth, and then torn
with the finger-nail.
_Excessive length_ of the frenum is occasionally met with, and in
children may allow of the tongue falling back into the throat and
causing sudden suffocative attacks, one of which may prove fatal. In
some cases the patient is able voluntarily to fold the tongue back
behind the soft palate.
_Macroglossia_ is the term applied to a variety of conditions in which
the tongue becomes unduly large, so that it tends to be protruded from
the mouth, and to become scored by the teeth. The typical
form--lymphangiomatous macroglossia--is due to a dilatation of the
lymph spaces of the tongue. It is often congenital, and may affect the
whole or only a part of the tongue. The enlargement may be progressive
from the first, or may remain stationary for years, and then begin to
develop somewhat suddenly, sometimes after an injury or as a result of
some infective condition. The treatment consists in removing a
wedge-shaped portion of the tongue.
In certain cases of macroglossia in children, the lesion has been
found to be a fibromatosis of the nerves of the tongue, analogous to
the plexiform neuroma.
_Atrophy_ of the tongue is rare as a congenital condition.
Hemi-atrophy occurs in various diseases of the central nervous system,
as well as after injuries and diseases implicating the hypoglossal
nerve.
#Nervous Affections of the Tongue.#--_Neuralgia_ confined to the
distribution of the lingual nerve is comparatively rare. It usually
yields to medical treatment, but in inveterate cases it is sometimes
necessary to resect the nerve.
It is more common to meet with a condition in which the patient
complains of severe burning or aching pain in the region of the
foliate papilla, which is situated on the edge of the tongue just in
front of the anterior pillar of the fauces. The patient is usually a
middle-aged, neurotic woman, and often with a gouty or rheumatic
tendency. The pain, for which it is seldom possible to discover any
cause, is usually worst at night, and may last for months, or even
years. The practical importance of the condition is that, as the
foliate papilla is prominent and red, it is liable to be mistaken on
superficial examination for a commencing epithelioma. An inspection of
the opposite side of the tongue, however, will reveal an exactly
similar condition, which is not painful. The first and most important
step in treatment is to assure the patient that the condition is not
cancerous. Caustics and other irritating applications are to be
avoided.
_Spasm_ of the tongue sometimes occurs after injuries of the head
implicating either the centre or the trunk of the hypoglossal nerve.
It may also appear as a reflex condition in infective affections of
the teeth and gums, or as a manifestation of some general disease of
the central nervous system.
_Paralysis_ of the tongue--unilateral or bilateral--may be due to
injury or disease of the nerve centres of the hypoglossal nerve, more
frequently to injury of or pressure on the nerve-trunk. The nerve may
be bruised or divided in operations for the removal of tuberculous
glands or other tumours in the neck. When the tongue is protruded it
deviates towards the paralysed side, being pushed over by the active
muscles of the opposite side (Fig. 260), and speech and mastication
may be interfered with. The paralysed half of the tongue subsequently
undergoes atrophy, but the functional disability largely disappears.
[Illustration: FIG. 260.--Temporary Unilateral Paralysis of Tongue,
from bruising of hypoglossal nerve during operation for tuberculous
cervical glands.]