exposure to the cause can be avoided. This holds good almost invariably
in cases due to over-medication with mercurials, but is far less
applicable to cases in artisans, the result of prolonged exposure to
the poisonous influences of mercury and its slow absorption. On the
whole, the affection is much less serious than formerly, both because
it can, in great measure, be guarded against by proper prophylaxis in
risky vocations, and because its treatment has been made much more
efficient. In severe cases serious results may ensue despite the most
judicious treatment, and convalescence is usually very slow, weeks
often elapsing before solid food can be chewed without pain or without
injury to the gums.
When death ensues, it may be by asthenia, erysipelas, pneumonia,
pyæmia, or colliquative diarrhoea.
TREATMENT.--Mercurial stomatitis may sometimes be prevented by the
administration of potassium chlorate during exposure. Mild cases
following the administration of mercurials often subside upon mere
withdrawal of the drug. Should spontaneous subsidence not take place,
the administration of potassium chlorate every few hours, in doses of
{348} from thirty to sixty grains or more in the twenty-four hours,
soon effects amelioration, which promptly terminates in recovery. The
characteristic fetor often ceases within twelve hours' use of this
drug. Should the inflammatory manifestations be severe, a few leeches
applied beneath the edge of the lower jaw, followed by a poultice
enveloping the neck to promote further flow of blood, often affords
prompt relief (Watson). Lead acetate (ten grains to the ounce of water)
and iodine (half a fluidrachm of the compound tincture to the ounce of
water) are useful as gargles and washes. When the result of slow
poisoning, elimination of the mercury by sulphur vapor baths and the
administration of small doses of potassium iodide are recommended.
Cauterization of the ulcerated surfaces is sometimes serviceable,
silver nitrate or hydrochloric acid (Ricord), or chromic acid 1:5
(Butlin, Canquil), being used for the purpose.
Opium in decided doses is indicated for the relief of pain. It may be
added with advantage to detergent and disinfective mouth-washes
(potassium chlorate, sodium borate, creasote-water, saponified emulsion
of coal-tar, tincture of cinchona, tincture of myrrh, etc.), the use of
which should form an important part of the treatment. Watson highly
recommended a wash of gargle of brandy and water, 1:4 or 5. In severe
cases difficulty is encountered in maintaining effective alimentation.
When mastication is not impracticable, soft-boiled egg and
finely-chopped raw beef may be given. When the patient cannot chew at
all, resort is confined to milk, soups, and the juice of beef.
Nourishing enemata should be administered, as in all affections where
it becomes impracticable to sustain the patient by way of the mouth.
Tonics and stimulants are indicated to avoid debility from the
excessive salivation and its sequelæ--quinia, coffee, wine, and
alcohol, the first, if required, by hypodermatic injection, all of them
by enema if necessary.
Glossitis and oedema of the larynx may require the surgical procedures
often necessary when they occur under other circumstances.
Other forms of toxic stomatitis hardly require special elucidation.
Abnormalities and Vices of Conformation of the Tongue.
Apart from the anomalies presented in monsters, there are a few
congenital abnormalities of the tongue with which it becomes the
accoucheur at least to be familiar, as their presence may interfere
materially with the nutrition of the infant, whether nursed or
spoon-fed.
CONGENITAL DEFICIENCY OF THE TONGUE.--A considerable portion of the
tongue may be wanting anteriorly, comprising, in some instances, the
entire free portion of the organ. The stump then presents as a single
or a bifid protuberance of variable size. In some instances
considerable power of movement exists, and even conservation of taste.
Suction and deglutition are both practicable. When the child grows it
can speak, though with a certain amount of difficulty. A few cases are
on record, however, of ability to speak without any evidence of a
tongue above the floor of the mouth.
An instance of lateral deficiency has been observed by Chollet,[16] the
{349} deficient half being represented merely by the two layers of the
lingual mucous membrane, without any intervening muscular substance.
[Footnote 16: Demarquay, _Dict. de Méd. et de Chir. prat._, xx. p.
130.]
BIFID TONGUE, separate investment of the two sides, has been
occasionally observed in connection with similar arrest of development
in the lower jaw and other organs.
Ankyloglossia.
DEFINITION.--An abnormal attachment or adhesion of some portion of the
tongue to some portion of the surrounding structures of the mouth.
SYNONYM.--Tongue-tie.
PATHOLOGY AND MORBID ANATOMY.--The ordinary form of tongue-tie consists
in an abnormal development of the frenum of the tongue, the anterior
vertical portion of the duplicature of mucous membrane which connects
the lower surface of the raphé of the tongue with the floor of the
mouth. The tongue cannot be extended beyond the lips. Suction is
interfered with in some cases. If not remedied spontaneously or by
surgical interference, mastication and articulation may become
seriously impeded.
Other forms of ankyloglossia, congenital and acquired, possess special
interest from surgical points of view mainly.
DIAGNOSIS.--Inspection and digital exploration readily reveal the
nature of the restriction in the movements of the tongue and the size
of the frenum.
PROGNOSIS.--The prognosis is good, the difficulty being susceptible of
relief by division of a portion of the constricting frenum. Accidents
have been reported following the operation, the occasional occurrence
of which should be borne in mind. These are hemorrhage, which is not
dangerous except in the prolonged absence of some one competent to
restrain it should it be extreme; and retroversion of the tongue, an
accident which has been known to prove fatal by occluding the orifice
of the larynx (Petit).
TREATMENT.--Slight cases rarely need operation; but when the movements
of the tongue are restricted by a very short and deep frenum its
division becomes necessary. The operation is usually performed with
scissors, the ranine arteries being protected by means of a fissured
plate of metal (Petit), such as has long been used as a handle to the
ordinary grooved director of the physician's pocket-case. The cut
should be more extensive in the lateral directions of the fold than
antero-posteriorly. After-treatment is rarely necessary, unless
annoying hemorrhage is produced by movements of suction. Compression
between the fingers, maintained for a number of minutes, suffices to
restrain the hemorrhage in most instances. When this fails, recourse
may be had to cauterization with the point of a heated iron or some
other form of actual cautery.
Macroglossia.
DEFINITION.--Hypertrophy of the tongue.
SYNONYMS.--Megaloglossia, Glossoptosis, Prolapsus linguæ, Lingua {350}
propendula, Chronic prolapse of the tongue, Chronic intumescence of the
tongue.
HISTORY.--This rare affection has been long known, the first cases on
record being in the works of Galen. Other cases have been recorded by
Celsus and Avicenna. Among more modern recorders may be mentioned
Scaliger (1570), Bartholin (1680), Benedict and Pencer; among recent
recorders, Lassus,[17] Percy,[18] Harris,[19] Humphrey,[20]
Gayraud,[21] W. Fairlie Clarke,[22] Bryant,[23] and the French
dictionaries in present process of publication; to all of which the
reader is referred for bibliographic, descriptive, and illustrative
details.
[Footnote 17: _Mémoire de l'Institut National_, 18--, an VI. t. i.]
[Footnote 18: _Dict. Sci. Méd._, t. xxvii.]
[Footnote 19: _Am. Journ. Med. Sci._, vol. vii., 1830, p. 17; vol. xx.,
1837, p. 15--both illustrated.]
[Footnote 20: _Trans. Med.-Chir. Soc. London_, 1853, p. 113.]
[Footnote 21: _Thèse de Montpellier_, No. 68, 1865.]
[Footnote 22: _Diseases of the Tongue_, London, 1873.]
[Footnote 23: "Surgical Affections of the Tongue," _Guy's Hosp.
Reports_, 1883, p. 102 _et seq._]
ETIOLOGY.--This affection is usually congenital, at least to a certain
extent, and augments with the growth of the child. It has been
attributed, on apparently insufficient grounds, to injury received
during parturition. It is probably intra-uterine in origin. Though
encountered in both sexes, the majority of recorded cases have been in
females. In summing up these observations, it appears that the
affection often attracts little or no attention until dentition is in
progress. The hypertrophy begins to augment rapidly during the second
or third year of age, or a year or two later in some cases.
The gradual increase of the congenital deformity during infancy has
been attributed to hypernutrition from local irritation produced by
habits of sucking on the organ, induced, in some subjects, by forcible
efforts at suction from a short nipple. Similarly, the rapid
augmentation of volume noted as occurring during the period of
dentition or a little later has been attributed to hypernutrition
excited by irritation suffered by the protruding organ from the lower
row of teeth. Cases commencing at this age have been supposed to be due
exclusively to tongue-sucking. In some instances, due to this cause
apparently, the deformity is associated with idiocy (Lawson[24]).
Convulsions, epileptic seizures, and whooping cough have been regarded
by some writers as occasional causes of the deformity. Indeed, idiocy
and cretinism are not infrequent co-associates with the deformity
(Parrot[25]). It has been observed likewise in anencephalous monsters
(Brissot, _idem_).
[Footnote 24: _Trans. Clin. Soc. London_, vol. v. p. 158.]
[Footnote 25: _Gaz. Méd. Paris_, Dec. 10 and 17, 1881; _Lond. Med.
Record_, Mar. 15, 1882, p. 113.]
SYMPTOMS, COURSE, DURATION, TERMINATIONS, COMPLICATIONS, AND
SEQUELÆ.--The prominent symptom of macroglossia is the enlarged tongue
protruding beyond the mouth. The resemblance of the protruding tongue
of a child with macroglossia to the tongue hanging from the mouth of a
calf gave rise to the name lingua vitulina by which it has sometimes
been designated. In some instances, where the enlargement is but
moderate, the organ can be retained within the mouth. When bilateral,
the enlargement may be symmetrical, or may interest one side of the
tongue more than the other. When the enlargement is confined to the
free portion of the tongue, it interferes little with respiration and
with movements of suction. When occupying the base of the organ, it may
seriously embarrass respiration, and even produce suffocation in {351}
some instances (Clarke). The mouth being maintained open, saliva
dribbles away constantly except during alimentation. Thirst is often
very great in consequence of this, and of the desiccation of the tongue
and of the walls of the mouth by the unmodified air to which they are
continuously exposed. The tongue is usually free from pain.
In some subjects, although the tongue, left to itself, protruded
considerably, it has been found quite practicable to maintain it within
the cavity of the mouth by means of bandages or other appliances
secured to the back and top of the head. These bandages are removed
from time to time to give relief from the restraint and to permit food
and drink to be taken. Systematic compression, indeed, has been induced
in this way in some instances, and has produced considerable diminution
in the size of the organ--sufficient to maintain its concealment
without the aid of an appliance. When the tongue cannot be retained
within the mouth the patient becomes unable to close the jaws. Hence
saliva dribbles constantly, save when food or drink is being taken. The
protruded portion of the tongue undergoes a livid discoloration,
sometimes diffuse, sometimes disseminated. Though sometimes remaining
comparatively soft in texture, it usually becomes hard, dry, rough,
fissured, ulcerated and sanious, covered with desiccating layers of
mucus and epithelium, and marked by indentations made by the edges of
the teeth, which sometimes seem almost to strangle it. Mastication,
deglutition, and articulation often become very difficult, and
respiration also, but less frequently. The lower lip becomes much
everted. The larynx and hyoid bone become drawn upward and forward by
the weight of the organ. The configuration of the lower jaw undergoes
considerable change, and the teeth become pressed out of position.
Dislocation of the jaw from this cause has been noticed (Chalk[26]).
[Footnote 26: _Trans. Path. Soc. London_, vol. viii. p. 305.]
These symptoms undergo aggravation with the growth of the subject, and,
while presenting general features of resemblance in all cases, vary
considerably in individual instances. Great difficulty is encountered,
as a rule, in taking food, and mastication has to be performed very
slowly. In some instances mastication can be performed satisfactorily
by the molars, owing to a compensatory curvature of the lower jaw, even
though the anterior portions of the jaw may remain permanently
separated (Harris). Some patients get along by using their fingers to
push the bolus far {352} enough back to permit of its deglutition. Some
have used a cup with a long tube slightly curved to convey fluids to
the back part of the mouth for a similar purpose. Some have been
systematically fed by means of a catheter passed through a nasal
passage and thus on into the oesophagus. The difficulties in nourishing
patients reduce some of them to extreme emaciation.
Notwithstanding all these drawbacks, quite a number of cases are on
record where the patients have reached well into adult life before
being submitted to radical measures for relief. One patient is recorded
as having reached the age of eighty, having worn for some sixty-five
years a silver shield to conceal her deformity (Clarke).
PATHOLOGY AND PATHOLOGICAL ANATOMY.--The hypertrophy may involve all
the structures of the tongue, but usually implicates the muscular
tissue especially (Sédillot, Paget, Bouisson). In a case published by
W. Fairlie Clarke it was found on microscopic examination that the
papillæ as well as the mucous and submucous tissues were somewhat
enlarged and thickened, while the bundles of muscular fibre were
slightly coarser than natural. Maas reports a unilateral case of
macroglossia in a male child two months of age associated with
hyperdevelopment of the entire left side of the body.[27] In some
instances the blood-vessels and lymphatics are chiefly involved
(Virchow, Billroth, Maas), two cases of which have been described by
Virchow as cavernous lymphatic tumors.
[Footnote 27: _Arch. klin. Chir._, p. 413, Bd. xiii. Heft 3.]
Hilliard reports[28] a congenital case from vicious growth, removed at
fourteen months of age. Microscopic sections showed the large lacunæ
filled with corpuscles, blood-pigment in different stages of
degeneration, {353} and the papillæ much hypertrophied. Winiwarter[29]
reports a congenital macroglossia associated with congenital cysts of
the neck.
[Footnote 28: _Brit. Med. Journ._, Nov. 26, 1870, p. 591.]
[Footnote 29: _Arch. klin. Chir._, 1874, Bd. xvi. Heft 3.]
Sometimes there is very little true muscular hypertrophy, as in a case
quoted by Bryant which was presented to the Pathological Society of
London in 1872 by M. H. Arnott. In this specimen the epithelial
covering was very thick and the papillæ enlarged. The blood-vessels
were larger than usual, and there were large irregular spaces,
thin-walled and filled with blood or clear fluid. "A few vesicular
bodies which may have been enlarged lymphatics were also
present"--probably cross-sections of lymphatic vessels.
The size that may be attained even in young children seems incredible,
three and four inches protruding from the mouth in some instances. The
free portion is more bulky than the intra-oral portion. One case
reported "as thick as an arm" probably refers to the arm of the child.
As a rule, both sides of the tongue are involved; exceptionally, the
affection is unilateral.
In most instances the hypertrophy occupied the free portion of the
tongue chiefly, the base of the organ having been implicated in but a
few.
[Illustration: FIG. 14. Chronic Intumescence of the Tongue (Harris).]
[Illustration: FIG. 15. Hypertrophy of the Tongue (Harris), before
operation and after. A, odontolith.]
DIAGNOSIS.--The presence of the tongue outside of the mouth speaks for
itself (Figs. 14 and 15). The age of the patient, usually a young
child, the history of the case if it present in the adult, suffice to
differentiate macroglossia from the tumefaction of glossitis on the one
hand and from certain protruding tumors and malignant diseases on the
other. Hypertrophy of the tongue following chronic glossitis,
syphilitic or non-specific, must not be confounded with the congenital
or idiopathic affection under consideration.
PROGNOSIS.--The prognosis is good as to relief from the deformity,
provided the patient is submitted to surgical interference, and the
prognosis of the operation depends upon the procedure selected.
Sometimes additional operations are requisite to remedy the defects the
lower jaw has sustained by prolonged depression. In comparatively young
adults restoration of its position, configuration, and function seems
likely to result spontaneously after the protruding portion of the
tongue has been removed.
TREATMENT.--It has been maintained (Lassus) that the hypertrophy can be
overcome by systematic compression of the tongue, by leeching the
tongue, bandaging or strapping it, and forcibly maintaining it in the
mouth by suitable retentive appliances. While it has been admitted that
this plan may prove successful in cases of moderate enlargement of but
few years' duration and unaccompanied with change in the shape of the
lower jaw, the experience of more recent observers has been recorded as
unfavorable, at least in pronounced cases. Clanny[30] succeeded in this
way with a child five years of age whose tongue protruded three inches.
This plan is said to be very painful and irritating. It requires close
watching on account of the difficulty of respiration which may ensue
from thus blocking up the pharynx. It has been advised as a useful and
sometimes an essential preliminary (Syme) to a radical procedure
consisting in the excision of a V-shaped segment. This latter operation
(Boyer) has been successfully performed by Howe, Harris, Humphry, Syme,
and others. {354} Frederici[31] extended the incisions to the very base
of the tongue. It has been performed both with knife and with scissors,
the cut surfaces being united with sutures after ligation or torsion of
the bleeding vessels. Re-enlargement ensued in one of Syme's cases
operated upon in this way,[32] and likewise in a case of Gies,[33]
requiring subsequent excision of the exuberant portions. Operations
with the ligature, though sometimes successful (Fergusson,[34]
Hodgson[35]), may be followed by fatal septicæmia during the slough
(Liston[36]), or, failing to strangulate the tongue sufficiently, may
require the application of the knife, after all, to affect the
separation (Harris[37]).
[Footnote 30: _Edinb. Med. and Surg. Journ._, 1805, vol. i., cited by
Clarke.]
[Footnote 31: _Arch. gén. de Méd._, 1844; _Edinb. Med. and Surg.
Journ._, p. 528, vol. lxiv., 1845.]
[Footnote 32: _Edinb. Med. Journ._, 1857, vol. ii. p. 1057.]
[Footnote 33: _Arch. klin. Chir._, 1873, p. 640.]
[Footnote 34: _Practical Surgery_, London, 5th ed., p. 518.]
[Footnote 35: _Trans. Med.-Chir. Soc. London_, 1858, p. 129.]
[Footnote 36: _Elements of Surgery_, p. 334, Philada., 1842.]
[Footnote 37: _Am. Journ. Med. Sci._, vol. vii. p. 17.]
Excision with the incandescent loop of the galvano-cautery seems to be
the most suitable procedure. Valerani[38] operated in this manner
without the loss of a drop of blood upon a congenital macroglossia in a
child seven months of age. Maas[39] operated in this way on a child two
months of age. Fairlie Clarke, who removed a congenital macroglossia
with the écraseur in a child five months of age, recommends operation
before dentition begins[40]--an opinion which appears to be justified
by the belief that the pressure of the teeth contributes to the
subsequent rapid enlargement of the organ. Nevertheless, the operation
may be undertaken at any age. Several of those already cited were
performed upon adults, and Stephen O'Sullivan[41] excised the
hypertrophied tongue of a female sixty-five years of age.
[Footnote 38: _Giornale della Reale Accademia di Turino_, fasc. 1518;
_London Med. Record_, Sept. 15, 1876, p. 408.]
[Footnote 39: _Loc. cit._]
[Footnote 40: _Lancet_, March 30, 1872, p. 432.]
[Footnote 41: _Dublin Journ. Med. Sci._, Aug., 1875, p. 178.]
Ignipuncture with the thermo-cautery of Paquelin has been successfully
used of late by Helferich and by von Bruns of Tübingen.[42] In the
latter instance the subject was five years of age. Fourteen punctures
were made from above downward at intervals of about one centimeter, and
five were made transversely. Not a drop of blood was lost. On the third
day secondary hemorrhage occurred from the intercommunication of three
of the punctures; this was restrained by ferric chloride, and the case
went on to a favorable conclusion. Surgical procedures must constitute
our sole therapeutic reliance. The temporary subsidence of enlargement
under the influence of mercury and the iodides seems sure to be
followed, sooner or later, by reproduction of the deformity. It is
therefore a waste of time to attempt cures by medication.
[Footnote 42: _Centbl. f. Chir._; _Med. Times and Gaz._, Sept. 23,
1883.]
Glossitis.
DEFINITION.--Inflammation of the tongue.
The term glossitis is usually applied to inflammation of the tissues of
the tongue as a whole (parenchymatous glossitis), and not to those
superficial inflammations which exist associated with the different
varieties of {355} stomatitis and with other affections, and which
implicate the mucous membrane and its glands and papillæ only
(superficial glossitis). Superficial glossitis, however, sometimes
terminates in parenchymatous glossitis. Papillæ and glands are usually
affected together in superficial glossitis. When the inflammation
predominates in the papillæ the disease is often designated as
papillary glossitis; when in the glands, it is often termed follicular
glossitis. Superficial glossitis, again, is sometimes manifested by the
eruption of vesicles on the tongue, under which circumstance it is
often denominated vesicular glossitis, sometimes herpetic glossitis.
Glossitis is sometimes restricted to a portion of the tongue
(circumscribed glossitis), and it sometimes involves the whole of the
tongue (diffuse glossitis). Either form may be unilateral
(hemiglossitis), though both forms are more frequently bilateral.
Either form may be acute or chronic.
Superficial Glossitis.
DEFINITION.--An inflammation of the mucous membrane of the tongue,
usually involving likewise both papillæ and glands.
SYNONYMS.--Catarrhal glossitis, Angina lingualis. Varieties: Papillary,
follicular, vesicular (herpetic and eczematous), psoriatic, ichthyotic.