is most frequently deuteropathic, and sometimes traumatic. Superficial
deuteropathic glossitis usually occurs in connection with gastric and
gastro-enteric affections. It occurs likewise in association with
stomatitis, tonsillitis, pharyngitis, many febrile affections,
scorbutus, tuberculosis, syphilis, so-called psoriasis and ichthyosis
of the tongue, carcinoma of the tongue, and the various neoplasms of
the organ. Irregular and sharp-cornered or jagged teeth often induce
traumatic superficial glossitis. Pungent vapors, such as those of
chloride of ammonium, so much used of late years in the treatment of
nasal catarrhs, sometimes produce a superficial traumatic glossitis,
usually localized on the superior surface of the anterior portion of
the tongue. Tobacco-smoking, especially from a short-stemmed pipe, will
likewise produce it occasionally at the point where the concentrated
smoke strikes the organ. Attempts to drink liquids too hot, too acrid,
or too caustic may be mentioned as other occasional causes. Nervous
irritation, such as of the chorda-tympani nerve, is attributed as a
causal influence of unilateral vesicular glossitis, herpetic or
otherwise, and as a probable factor in other varieties of unilateral
glossitis. Eczema of the tongue may ensue as a sequel of prolonged
cutaneous eczema (De Mussy[43]).
[Footnote 43: _Gaz. hebd._, June 22, 1883; _Med. News_, Aug. 11, 1883,
p. 151.]
PATHOLOGY AND MORBID ANATOMY.--Superficial glossitis, as indicated,
involves the mucous membrane, glands, papillæ, and epithelium. It is
hardly necessary to dwell upon the pathological conditions of the
lingual mucous membrane and its epithelium in gastro-intestinal and
febrile disorders, as these are described in connection with the
various diseases. Ordinarily, the epithelium increases in thickness,
and when detached, spontaneously or otherwise, exposes a red and
swollen membrane with erect papillæ. Sometimes the condensed stratified
layer of epithelium becomes dry and very hard. Under some illy-defined
{356} conditions, the papillæ of the tongue undergo great hypertrophy.
The filiform papillæ become elongated to several times their normal
length, and feel and look like so many hairs on the tongue. Like many
other lingual affections, this is often unilateral. It is quite marked
in some cases of influenza and other febrile disorders, producing great
annoyance in the mouth. It occurs likewise in gastro-intestinal
disorders and in disorders of the mouth and teeth. It is evidently a
deuteropathic phenomenon. In other cases the glands of the tongue,
especially at its base, become involved, forming the follicular
glossitis of some writers. In another class of cases, most frequently
syphilitic or at least quasi-syphilitic, one or more whitish
circumscribed patches are seen on the tongue, resembling such as are
left after superficial cauterization with nitrate of silver. This
condition is described as psoriasis linguæ. It is due to condensation
of layers of epithelium, which may become detached in a few days in
mass or in fragments, leaving the denuded mucous membrane red and the
papillæ erect and somewhat swollen.
When psoriasis of the tongue has existed for a long time, a further
change, and a more permanent one, takes place in the papillæ and
epithelium. This condition has been denominated ichthyosis linguæ.
Superficial ulceration takes place at the psoriatic patches, and the
repair eventually excites such a proliferation of epithelium that it
becomes quite horny to the sight and to the touch. It spreads over a
much larger extent of surface than the original psoriasis, but, like
it, leaves the unaffected portions of the tongue in an apparently
normal condition. Both affections are usually bilateral, and the
patches or series of patches most frequently symmetrical or engaging
analogous vascular territory upon the two sides.
In a case reported by Mr. Hulke[44] portions of the horny substance
were habitually sliced off with a razor. Microscopic examination
"showed colossal papillæ; the indurated portion of the mass was
altogether epithelial, the lower cells being clear, transparent, and
natural, the middle ones granular, and the superficial layer felted
together into a dense opaque mass" (Clarke).
[Footnote 44: _Medical Times_, Nov. 30, 1861, p. 556.]
Both of these affections are liable in about one-third of the cases to
terminate in epithelioma. Although the opinion generally entertained
classes all cases of psoriasis and ichthyosis linguæ in the category of
syphilitic affections, there is reason to doubt its accuracy.
Sangster[45] has drawn up a tabular statement of 44 cases, of which 1
only occurred in a female; 23 occurred in smokers, 12 being inveterate
smokers. In but 12 instances (8-1/3 per cent.) was there positive proof
or strong evidence of syphilis; 30 per cent. of the whole number
eventuated in epithelioma.
[Footnote 45: _Med. Times and Gaz._, London, April 8, 1882, p. 370.]
Vesicular glossitis, usually unilateral and most frequently
right-sided, has been described by Paget,[46] Stoker,[47] Barker,[48]
Hill,[49] and De Mussy,[50] and doubtless by others.
[Footnote 46: _Lancet_, March 11, 1865; Clarke, _op. cit._, p. 88.]
[Footnote 47: _Dub. Journ. Med. Sci._, May 1, 1876, p. 401,
illustrated.]
[Footnote 48: _Lancet_, Nov. 22, 1879, p. 764.]
[Footnote 49: _Brit. Med. Journ._, Oct. 7, 1882, p. 683.]
[Footnote 50: _Gaz. hebd._, June 22, 1883; _Med. News_, Aug. 11, 1883,
p. 151.]
{357} SYMPTOMATOLOGY, COURSE, DURATION, TERMINATIONS, COMPLICATIONS,
AND SEQUELÆ.--Dryness of the tongue, stiffness, heat, and pain--the
latter especially during movements of the organ in deglutition and in
articulation--are the prominent subjective symptoms of acute
superficial glossitis. There are rarely any marked symptoms of febrile
disturbance unless the disorder is about to undergo extension into
parenchymatous glossitis.
DIAGNOSIS.--Redness of the tongue, prominence of the papillæ, slight
enlargement, perhaps bearing impressions made by the teeth, and pain or
sense of impediment on movement, are the main diagnostic features of
superficial glossitis.
Vesicles indicate the vesicular variety of superficial glossitis;
irregular whitish patches, the psoriatic variety; and hard, horny
patches with intervening fissures, the ichthyotic variety. A
superficial circumscribed glossitis attending the local ulcerations of
syphilis, tubercle, and epithelioma is differentiated by the clinical
history of the case.
TREATMENT.--In ordinary cases the treatment described under catarrhal
stomatitis suffices, so far as local measures are concerned. The
gastritis or gastro-enteritis requires appropriate attention, as does
any systemic malady under which the patient may be laboring. Demulcent
and astringent lotions may be applied by douche, spray, or gargle.
Local applications of weak solutions of iodine have been recommended.
In cases of considerable severity, and especially when there is reason
to expect extension into the deeper tissues, superficial scarification
of the dorsum of the tongue is advisable.
Ulcers are perhaps best treated locally by touching the edges daily
with the pencil of sulphate of copper. Any imperfect teeth in their
immediate vicinity to which the ulceration may be attributable should
be extracted or put in repair. De Mussy's case of eczema was cured
after five months' daily use of a large quantity of water-cress.
Glossitis Parasitica.
DEFINITION.--An inflammation of the tongue said to be due to parasitic
vegetation.
SYNONYMS.--Nigrities, Glossophytia, Black tongue.
Under the term black tongue two different affections have been
described, the one an epidemic erysipelatous disorder to be mentioned
under parenchymatous glossitis, and the other, now to be mentioned, a
peculiar black pigmentation due to parasitic disease seated upon and
around the hypertrophied filiform papillæ. The ordinary parasitic
vegetations found upon the tongue do not produce the affection in
question.
HISTORY.--First described by H. Hyde Salter,[51] and then by Eulenburg,
it has been made the subject of observation by Raynaud,[52] Fereol and
others,[53] Lanceraux,[54] Dessois,[55] Hirz,[56] Pasquier,[57]
Moure,[58] and a few {358} others. Outside of French literature, little
had been written of it until very recently.
[Footnote 51: Article "Tongue," _Encyclopedia of Anatomy and
Physiology_, London, 1849-52, vol. iv. pp. 1159, 1160.]
[Footnote 52: _Gaz. hebd._, 1869, No. 14, p. 221.]
[Footnote 53: _Gaz. des Hôp._, June 29, 1875.]
[Footnote 54: _Union Méd._, March 20, 1877.]
[Footnote 55: _De la Langue noire [Glossophytie]_, Paris, 1878, 8vo, p.
38, illustrated.]
[Footnote 56: _Gaz. Méd._, Strasbourg, 1879.]
[Footnote 57: _Bull. Méd. du Nord_, 1883.]
[Footnote 58: _Revue mensuelle de Laryngologie, etc._, Sept., 1883, p.
276.]
ETIOLOGY.--The affection appears to be due to some fault of nutrition,
but the cause has not been determined. The fluids of the mouth always
exhibit an acid reaction. It has been seen chiefly in dyspeptics and
hypochondriacs, and has seemed in one instance (Moure) to have followed
the use of chlorate-of-potash lozenges. A case has been recorded by
Solomon Solis Cohen[59] in a negro child the subject of congenital
syphilis. Mr. George Stoker[60] and G. Y. Broatch[61] have each
reported a case of long duration occurring in a painter.
[Footnote 59: _The Polyclinic_, Philada., July, 1884, p. 10.]
[Footnote 60: _Brit. Med. Journ._, March 29, 1884, p. 602--said to be
first case recorded in England.]
[Footnote 61: _Ibid._, April 19, 1884.]
PATHOLOGY AND MORBID ANATOMY.--The disease is characterized by a
grayish-black or fully black discoloration on the upper surface of the
tongue, which gives it an aspect which recalls the normal appearance of
the tongue of the parrot and the giraffe, and an occasional appearance
of the organ in the ox, sheep, dog, cat, and some other animals. The
filiform papillæ are enormously elongated, so that they closely
resemble hairs, and they are described by some writers as lying upon
the surface of the tongue in confusion like that of a field of wheat
thrown down by the wind. The individual papillæ are surrounded with a
parasitic vegetable growth. Raynaud compared the microscopic spores in
his case to the microphyte of tinea tonsurans or that of herpes
circinatus. According to Malassez, they do not differ from those found
in the saburral tongue of the dyspeptic, and he considers that their
development is favored by their very arrest by the hypertrophied
papillæ. Nevertheless, the subjects of this disease are not all
dyspeptics by any means. Dessois made culture-efforts to reproduce the
disease upon his own tongue, but failed to inoculate it. For detailed
description of the disease we cannot do better than refer the
interested reader to Dessois' monograph, from whose observations,
chiefly, it appears that the discoloration begins at the central
portion of the tongue, increases gradually in extent and intensity for
three or four days, and then gradually disappears by desquamation. The
tongue is very dry while the affection is at its height. Close
examination of the parts and microscopic inspection of papillæ removed
for the purpose are said to show that the spores of the cryptogam are
first developed at the base of the papillæ, separating them from each
other. The irritation produced by the parasite causes longitudinal
hypertrophy of the papilla, and the continued growth of the parasite
produces a muff-like envelopment of the papilla; the spores at the same
time becoming insinuated between the most superficial epithelial cells
and dislocating them, so that they maintain their position around the
axis of the papilla only by means of the intervening parasitic masses.
The papilla continues to elongate and the cryptogam to increase, until
finally it invades nearly the entire length of the papilla. This entire
parasitic mass soon becomes detached, carrying with it the epithelial
cells under which it has become insinuated, and leaves the papilla
naked, save for a few cells remaining attached by their superior
borders. In the case observed by my brother, as in Mr. Stoker's and
Broatch's cases, microscopical examination of the black filaments
showed them to be composed of closely-packed epithelial cells,
overlapping one another, stained {359} brown, and decreasing in
intensity of color from the apex toward the base of the filament. In
some cells the nucleus was darker, and in others lighter, than the
surrounding protoplasm. The cryptogam, therefore, cannot always be
detected. Indeed, there seems reason to believe that the affection may
not be parasitic,[62] although the prominence given to this feature by
French writers apparently warrants its being so considered. There may
be two kinds of black tongue--one non-parasitic.
[Footnote 62: Hutchinson, _The Medical Press_, p. 20, July 11, 1883.]
SYMPTOMS.--There are no special subjective symptoms. The objective
symptoms are the peculiar dark or black discoloration of the upper
surface of the tongue and the excessively elongated filiform papillæ.
DIAGNOSIS.--The chief diagnostic feature is the black discoloration of
the tongue which has given the name black tongue to the disease.
Discrimination is requisite from discoloration by food or medicine.
PROGNOSIS.--This is favorable, the condition subsiding under treatment,
and sometimes spontaneously, though liable to recurrence. In some
instances the condition becomes chronic.
TREATMENT.--The indication is to endeavor to favor desquamation of the
papilla by means of potassium chloride or sodium borate, and to
administer alkalines, so as to render the saliva alkaline and
unfavorable for the development of the parasite. It is recommended, in
addition, to scrape the tongue with a spatula, and to douche it with a
spray of mercuric chloride, 1:500. Attention to the general health is
requisite, especially in dyspeptics and hypochondriacs. In the case of
the negro child above alluded to the discoloration of the tongue
finally disappeared under the systemic use of potassium iodide, without
topical treatment, although repeated recurrences took place at varying
intervals.
Parenchymatous Glossitis.
DEFINITION.--An inflammation of the tongue involving its substance as
well as the mucous membrane.
SYNONYMS.--Idiopathic glossitis. Interstitial glossitis. Erectile
glossitis (Salter), Glossomegistus (Sauvages), Paraglossia.
HISTORY.--Albeit a comparatively infrequent disease, especially at the
present day, numerous cases and collections of cases are on record from
very early times; and the affection seems to have attracted the
attention of medical writers ever since. Hippocrates, Galen, Aretæus,
Celsus, Aëtius, Avicenna, Forestus, Rivière, Schenkins, Sauvages,
Vogel, van Swieten, are referred to by more modern writers as having
described the disease. Louis, De la Malle, Lassus, J. P. Frank, Jn.
Frank, Fleming,[63] Clarke, and Bryant may be cited as the most
prominent recent observers.
[Footnote 63: _Dublin Journ. Med. Sci._, 1850, vol. x.]
ETIOLOGY.--Predisposing and Exciting Causes.--Glossitis is sometimes
idiopathic, sometimes deuteropathic, and sometimes traumatic. Impaired
health from over-fatigue or from exhaustive disease may be regarded as
a predisposing cause in the presence of the causes which more
frequently give rise to traumatic glossitis. Sudden or prolonged
exposure to atmospheric changes, to cold and moisture, as when working
in damp and wet localities, is often the apparent determining cause in
{360} both the idiopathic and deuteropathic varieties. In many
instances occurring in this way it is found that the tongue has long
been subjected to mechanical irritation from jagged teeth.
Idiopathic glossitis occurs at all ages, but has been supposed by some
observers to be more frequent in scrofulous subjects. It occurs in the
apparently healthy only after severe exposure to wet and cold, and in
convalescents from acute febrile diseases usually after some moderate
exposure to a draught of air or change of temperature. It appears to be
more imminent after influenza (Möller, Smee, Graves, Salter) than after
other febrile disorders. It has occasionally been caused by chewing
acrid plants, some of them food-plants, some of them medicinal. In the
list have been included celery, bilberries, Daphne mezereum and Daphne
laureola, aconite, and tobacco. It has been known to follow the eating
of shellfish (Watson, Salter).
Deuteropathic glossitis has occurred during the course of scarlatina,
variola, epidemic erysipelas (black tongue), scorbutus, enteric fever,
glanders, septicæmia from various causes, rheumatism, diffuse
inflammation of the connective tissue of the cervico-mental region,
herpes, syphilis, ptyalism, mercurial and other varieties of toxæmic
stomatitis, tonsillitis, pharyngitis, gastritis, and epithelioma of the
tongue. It appears to be occasionally endemic (Fleming[64]), and is
occasionally epidemic (Reil[65]). In the United States it prevailed
extensively during an epidemic of erysipelas that overran the country
from 1842 to 1846, inclusive, and was frequently reported in the
American medical journals of that period under the name of black
tongue. In some localities more than half the cases terminated fatally,
sometimes within two or three days, more frequently about the eighth or
tenth day, and occasionally still later. Traumatic glossitis arises
from a number of causes. Among these may be mentioned the irritation of
jagged edges of broken and carious teeth; wounds from firearms and
other weapons; wounds from splinters of toothpicks, spiculæ of bone,
broken pipe-stems, pins, needles, nails, slate-pencils, and other
pointed things inadvertently placed in the mouth; wounds from the teeth
during epileptic seizures and other convulsive paroxysms; contact of
the tongue with cold iron in cold weather; the inspiration of very hot
air, as in burning buildings; burns, scalds, scalding beverages; acrid
and corrosive substances introduced by design or accident; incautious
use of tobacco in bulk, and of ammonia; incautious cauterization;
concealed calculi in the tongue; concealed bulbs of teeth; rupture of
the lingual frenum; the bites and stings of venomous insects, as the
wasp, the hornet, and the bee. For many years writers have referred to
a case reported by Dupont to the Parisian Academy of Medicine which
followed a young man's attempt to win a wager that he would bite into
the body of a living toad, and to two fatal cases reported by Ambrose
Paré from drinking a vinous infusion of sage which was subsequently
found to have been impregnated with the saliva of the toad.
[Footnote 64: _Dub. Journ. Med. Sci._, 1850, vol. x. p. 88.]
[Footnote 65: _Memorabilia Clinica_ (_Dict. Sciences méd._), vol.
xviii.]
SYMPTOMS, COURSE, DURATION, TERMINATIONS, COMPLICATIONS, AND
SEQUELÆ.--In acute parenchymatous glossitis the local symptoms often
appear quite suddenly, usually unilaterally, even when they become
bilateral subsequently, and they increase in severity with great
rapidity. {361} These symptoms are, at first, distinct sensations of
heat and tumefaction in the tongue, quickly followed by stiffness and
considerable impediment in its movements, as though it were numb and
weighted down. In cases where the glossitis is an extension from
tonsillitis, these sensations begin in the root of the organ. They
commence at the root likewise, in most instances following exposure to
severe cold and moisture. In other instances the extremity of the organ
is affected first. In cases resulting from local injury the symptoms
commence at the injured portion. The local symptoms are sometimes
preceded by rigor, followed by fever, cephalalgia, and pains in the
neck and occiput. Examined at this time, the tongue is seen to be
swollen and studded with indentations due to the pressure sustained
from the teeth. At first the surface is punctated and red; subsequently
it becomes brownish or decidedly brown. Although the organ may remain
moist for several hours, it eventually becomes excessively dry, and
supports a thick adhesive coating of mucus and epithelium.
[Illustration: FIG. 16. Glossitis (Liston).]
In a few hours, sometimes as few as two or three, the entire organ may
become involved in the inflammation, enlarging to such an extent as to
keep the lower jaw depressed, to fill almost the entire oral cavity or
to quite fill it, and to project like a tumor beyond the teeth and the
lips (Fig. 16). In exceptional cases the enlargement of the tongue has
been so great as to produce dislocation of the lower jaw. The soft
palate is lifted up and the epiglottis often pressed down. The latter
condition has been known to threaten suffocation. In this condition the
patient cannot breathe through the mouth, widely as it may be forced
open, and has great difficulty in breathing through the nose.
Respiration is therefore laborious. Articulation is impeded or
impossible, and deglutition difficult or impracticable. The tumefaction
and congestion are often continuous into the floor of the mouth and the
parts adjacent. The sublingual and submaxillary glands often become
swollen, tense, and painful; and the entire neck is sometimes swollen
to such a degree as to exert injurious pressure on the jugular veins.
The tongue is very hard to the touch, almost or quite immovable, and is
the seat of burning heat and pain. The pain often extends from the root
of the tongue along the glosso-pharyngeal folds into the pharynx, and
thence by way of the Eustachian tubes into the ears, the folds just
named being very much upon the stretch. When the tongue protrudes far
out of the mouth it becomes excessively dry, fissured, sanious, and
excoriated, or even ulcerated at points where it is subjected to the
pressure of the teeth. It is covered with dark viscid secretions, which
often extend beyond it and over the entire aperture of the mouth. The
epithelial coating often undergoes desquamation, and then the organ
becomes exquisitely sensitive to the contact of food, water, or even
the air. This desquamation is sometimes in mass, in sheets peeling off
like a pseudo-membrane. The general symptoms vary in individual cases.
As a rule, the face is turgid and its expression anxious; the
conjunctiva suffused, respiration impeded, and sleep disturbed or
impracticable. Saliva dribbles externally, often in considerable
quantity. The {362} odor from the mouth becomes quite fetid from
decomposition of the retained products of secretion. Thirst is usually
intense, though immoderate only in some cases. Cough is more or less
constant and quite exhausting. This and the dribbling of saliva
contribute with the dyspnoea to prevent sleep. Pyrexia is often
intense. The pulse is strong and quick at first, 100-120 per minute,
and there is often marked throbbing of the temporal and carotid
arteries. The skin is hot and dry at first, but cold sweat subsequently
accumulates upon the face and neck as the dyspnoea increases. The
bowels are constipated. The urine is scanty and high colored. The
impediment to the return of blood to the heart from the head causes
cerebral congestion, drowsiness, and even threatens asphyxia. In other
cases there is intense cephalalgia, nervous irritability, restlessness,
and even delirium.
The symptoms sometimes reach their acme in rather less than forty-eight
hours, and then gradually subside. More frequently they continue on
into the third or fourth day. Occasionally they are protracted as long
as the fifth or sixth or even the eighth day, rarely longer. Resolution
occasionally takes place within twenty-four hours, however (van
Swieten), though more frequently occurring from the fifth to the
seventh day. In some instances remittance or intermittence has been
noted, the cause therefor not being apparent, although attributed to
malaria.
Resolution of the inflammatory process is usually indicated by the
gradual return of moisture on the tongue and progressive detumescence
of the organ, accompanied by subsidence of the redness, heat, and pain.
Increased secretion of saliva, general perspiration, or diuresis
sometimes marks the cessation of the pyrexia.