distress increases, markedly about the end of the week. The pains
become lancinating, and associated with throbbing of the lingual
blood-vessels. The swelling becomes prominent and softer at some one
point, although the sense of fluctuation is not very perceptible on
palpation, and finally the abscess bursts through the surface, unless
previously incised, and discharges a fetid pus. Suppuration always
involves a prolonged duration of the attack.
In rare instances glossitis terminates in gangrene of the tongue,
circumscribed or diffuse. This result is indicated by adynamic symptoms
on the part of the constitution, and by the livid appearance of the
parts undergoing mortification. The hemorrhage following extensive
sloughs from gangrene has been fatal in some instances.
Fleming[66] calls prominent attention to a complication of glossitis,
of which he alludes to several examples. This is "an inflammation,
circumscribed or diffused, originating in the loose areolar tissue
between the genio-hyo-glossi muscles, and first manifesting itself by a
train of symptoms identical with those of ordinary glossitis, but soon
characterized by peculiar features." These features comprise fulness
under the chin like that dubbed double chin, pressure upon which,
especially near the hyoid bone, being very painful; and suppuration,
which, circumscribed or diffuse, burrows most freely toward the base of
the tongue.
[Footnote 66: _Loc. cit._, p. 91.]
Chronic induration of the tongue sometimes remains unilateral, although
the acute disease has not been unilateral.
{363} PATHOLOGY AND MORBID ANATOMY.--It has been advanced that in
idiopathic glossitis from cold the engorgement of the vessels is
probably a consequence of vaso-dilator influence of the
glosso-pharyngeal nerve for the base of the organ, and of the
chorda-tympani for the anterior portion. An instance of herpetic
glossitis from probable irritation of the chorda-tympani nerve by an
aural polypus (Berkely Hill[67]) seems to lend some force to this
opinion. However engendered, there is a rapid distension of the organ
by blood, followed by infiltration of fibrin and serum into the
intermuscular connective tissue and into the planes of the connective
tissue separating the muscular fasciculi. In some instances
degeneration of muscular fibre has been observed. There is great
increase in the thickness of the coats of epithelium, beneath which the
mucous membrane is red and its papillæ erect. This coating sometimes
peels off like a false membrane. In cases extending from tonsillitis
the base of the tongue suffers most.
[Footnote 67: _Brit. Med. Journ._, Oct. 7, 1882, p. 683.]
The disease usually terminates by resolution, although a slight amount
of hypertrophy, unilateral or bilateral, sometimes persists, and
occasionally to a marked degree (Wells). In instances much less
frequent suppuration ensues, usually in debilitated subjects or in
cases due to traumatism or in cases inefficiently treated. The
suppurative process is usually circumscribed and unilateral, and the
abscess points most frequently just beneath the side of the tongue;
sometimes, however, the pointing takes place at the dorsum, sometimes
at the tip. The pressure of the teeth seems to be the provocative cause
of the disposition to point at the edge of the tongue. The pus is
usually quite fetid. Sometimes the abscess is gangrenous.
Gangrene is an infrequent result of glossitis. The pressure of the
teeth, strangulating the organ at the oral outlet, seems to occasion
the failure of nutrition in instances where it occurs. The losses are
ordinarily insignificant, though appearing quite extensive while the
tongue remains swollen. Sometimes large portions drop off, and fatal
hemorrhage has resulted (Frank) in consequence. From the nature of the
organ the parts separate more readily than in almost any other
instance. Gangrenous abscess, ensuing even from very slight causes,
such as a wound with the head of a barleycorn (Ranking[68]), sometimes
proves fatal.
[Footnote 68: _Provincial Med. and Surg. Journ._, 1844.]
In those cases of diffuse inflammation of the interconnective tissue of
the genio-hyo-glossi muscles Fleming states that the
suppuration--which, whether circumscribed or diffuse, burrows toward
the root of the tongue--absolutely dissects its extrinsic muscles and
destroys their functions; ultimately injuring the periosteum and laying
bare the inside of the inferior maxilla in the vicinity of their
attachments. When an incision is made to the parts through the
integument, the muscles will be found on palpation flabby and detached,
and their interstices filled with purulent matter, sometimes very
fetid.
DIAGNOSIS.--These is no difficulty in the diagnosis, except in the
early stage of such examples as are attributed to metastatic gout and
rheumatism. The subsidence of the peculiar pains elsewhere, and the
onset of pain in the tongue, would lead to the inference that a
glossitis of this kind {364} was in progress. The acuteness of the
tumefaction would distinguish it from hypertrophy of the tongue on the
one hand, and from the tumefaction attending malignant disease on the
other.
Cystoma of the tongue has sometimes been mistaken for abscess due to
glossitis; but even here the history of the case should serve in most
instances as a satisfactory factor for the differential diagnosis.
PROGNOSIS.--The prognosis depends upon the gravity of the local
symptoms and the activity of the treatment. A case left to itself will
be likely to terminate fatally within five or six days. Death, indeed,
has been known to take place within forty-eight hours, even in cases
submitted to treatment. On the whole, however, the prognosis should be
regarded as favorable in the absence of specially lethal complications.
Even suppuration adds little gravity to the prognosis, the structure of
the organ being but little favorable to accumulations of purulent
material. Should an abscess become gangrenous, however, the prognosis
becomes grave at once, as it in the presence of gangrene from pressure
or other cause. Should the patient survive losses by gangrene, there
may be permanent impairment in articulation.
TREATMENT.--Superficial glossitis, as a rule, merely requires active
purgation, with the topical use of cold emollient mouth-washes
containing mucilage of slippery elm, quince-seed, or the like, to which
detergents, such as alum and borax, may be advantageously added in the
proportion of five grains to the ounce. In cases resisting this mild
treatment topical applications of glycerite of tannin twice or thrice a
day are often serviceable.
Parenchymatous glossitis demands the most active antiphlogistic
treatment. If the case be seen at an early stage of the process, before
the tumefaction of the tongue has become so great as to fill the mouth
and interfere with swallowing, a saline purge--say salts and
senna--containing some tartar emetic can be advantageously administered
to begin with. Following this, tartar emetic may be continued in small
doses every two or three hours, associated with small doses of tincture
of aconite-root (minim j-iij), according to the condition of the pulse
and the effect of medication. Should this treatment fail to produce
prompt amelioration in the local symptoms, or should the tongue be
considerably swollen when the case comes under care, free leeching
should be applied from the hyoid bone to the angle of the jaw on each
side, including the region of the hyoid bone (fifteen to twenty-five
Spanish leeches). This should be followed by emollient cataplasms,
reaching from ear to ear, to favor continuous hemorrhagic oozings from
the leech-bites. The internal antiphlogistic treatment is indicated
just the same, and if not administrable by the mouth may be
administered by the bowel; the nauseant and depressent effects of the
tartar emetic and aconite being maintained by hypodermatic injection.
Leeching the inflamed tongue itself is said to be often prompter in
producing detumescence of the organ than leeching exteriorly, but the
leech-bites are apt to add to the local irritation; besides which, the
mouth is so filled by the swollen tongue as to leave little more than
the tip accessible to the leeches without danger of losing control of
them. Venesection from the arm, the jugular vein, or from vessels
elsewhere is no longer much in vogue, it being doubtful whether general
venesection is more useful than local bleedings. Debility, whether
presenting originally or as the result of withdrawal of blood and other
{365} antiphlogistic measures, may be met by the systematic use of
tincture of chloride of iron and of quinia.
Severe cases demand one or more longitudinal incisions on each side of
the raphé of the tongue, deep enough to reach nearly halfway into the
substance of the organ and carried from base to tip. Cases are on
record in which the patients themselves had in their despair cut into
their tongues in order to obtain relief from their local sufferings,
and had in this way rescued their own lives by the means most
appropriate for the purpose (Camerarius, Lusitanus[69]). When the mouth
is filled by the tongue, it is necessary to insert the knife on the
flat until the base of the tongue is reached, and then to turn it and
make the cuts as indicated. Copious bleeding usually follows these
incisions, often followed by marked diminution in the volume of the
organ. Deep as these cuts appear when made, they become quite shallow
before the organ has shrunk to its normal volume. Bleeding from the
ranular veins, recommended by some practitioners in preference to
incisions into the organ, is often impracticable on account of the
tumefaction preventing access to them.
[Footnote 69: _Dict. Sciences méd._, vol. xviii.]
If severe hemorrhage takes place from divided vessels, the vessels may
be subjected to torsion, which is the preferable mode of management, or
to searing with some form of the incandescent cautery (hot iron,
electric cautery, Paquelin's thermo-cautery). Astringent and chemical
styptics are of little use. The method of searing is open to the
objection that secondary hemorrhage may ensue on detachment of the
eschars, but this accident is not likely to happen under circumstances
at all favorable.
In localized or circumscribed glossitis the incision to be made should
interest the swollen portion only.
Should the tongue swell again, the incisions may be repeated. Whether
the tongue require incision or not, it is good treatment to have the
patient inhale vapor from hot vinegar, alcohol, or cologne spirits to
render the parts more comfortable. Washes of weak detergent solutions
containing potassium nitrate, sodium borate, or ammonium chloride may
be used by syringe or spray to cleanse the parts and promote detachment
of the epithelial coatings on the tongue and interior of the mouth, the
accumulations of which are sometimes matters of great annoyance. The
drug last mentioned exerts in addition a special action on the
inflammatory process which is often quite serviceable. I have seen good
results follow the prolonged use of sprays of an aqueous solution of
ammonium chloride (Stuver), one drachm to the ounce, from the
steam-spray apparatus, continued for fifteen to twenty minutes at a
time and repeated every two or three hours.
In many instances the patient is unable to take food by the mouth. The
best plan under such circumstances is to pass a catheter into the
stomach through the larger of the two nasal passages, and retain it in
position unless its presence interferes too much with respiration. Milk
and stimulus can then be poured into the stomach from time to time with
the aid of a funnel passed into the outer opening of the tube, which
should be kept corked during the intervals when retained in position.
This failing or impracticable, it will be necessary to nourish the
patient with enemata.
On the appearance of abscess the same should be freely laid open. In
cases of hesitation, the true nature of the presumable abscess can be
{366} determined beforehand with the exploring-needle. The pus from an
abscess of this kind is rarely copious and is usually fetid. It would
be good practice to distend the sac after discharge of pus by injecting
into it a solution of carbolic acid.
In resisting or advanced cases of suppurative inflammation of the
planes of connective tissue between the muscles at the lower portion of
the root of the tongue, Fleming recommends a free incision under the
chin in the middle line, through skin and fasciæ and on through the
raphé of the muscles themselves.
In cases of gangrene, washes, douches, or sprays of carbolic acid,
chlorinated soda, hydrogen peroxide, or potassium permanganate are
indicated to relieve fetor; while the most supporting treatment by
mouth or otherwise is requisite on general principles.
Chronic Glossitis.
Chronic glossitis, like acute glossitis, may be superficial or
parenchymatous.
Chronic Superficial Glossitis.
Superficial chronic glossitis is usually confined to the papillæ of the
tongue, territories of which, so to speak, are mapped out on the
surface of the tongue, separated by furrows reaching to the basement
mucous membrane. In pronounced cases the dividing furrows are quite
deep, giving the organ a mamelonnated appearance, and they penetrate
into the mucous membrane (dissecting glossitis, Wunderlich), which
becomes subjected to great irritation by the retention of articles of
food in the fissures. Demarquay[70] has recorded a case of this kind in
which, to relieve the intense sufferings with which the patient had
been plagued for a number of years, he had been forced to amputate the
anterior half of the organ--an operation which succeeded thoroughly.
[Footnote 70: _Loc. cit._, p. 142.]
In another group of cases the surface of the swollen tongue is mapped
out in small ovoid patches, smooth, red, and glossy, from which the
papillæ have become separated without regeneration. Sometimes chronic
glossitis presents as an aphthous inflammation. Sometimes superficial
ulcers occur upon the dorsum of the tongue, irritable, indolent, and
indurated.
ETIOLOGY.--Chronic superficial glossitis is in rare instances a sequel
of the acute form of the disease. Usually, however, it is encountered
as a chronic affection from the outset, so to speak, generally as a
result of long-continued irritation in connection with dyspepsia and
other gastric and gastro-intestinal disorders. It is frequently
encountered in subjects of chronic alcoholism.
The superficial ulcerations often occur at the sides of the organ,
usually in some of the depressions formed by the contact of the teeth.
SYMPTOMATOLOGY.--The symptoms are those due to a consciousness that the
tongue is too large, with occasional pain in taking acid and succulent
food.
{367} PATHOLOGY.--The pathology does not differ from that of chronic
inflammations elsewhere. The apparent obliteration of the papillæ in
some cases is due to a filling up of the intervening furrows by
permanent deposit of new-formed cells. The excoriations and superficial
ulcerations are most frequently due to disturbance of nutrition by
pressure.
DIAGNOSIS.--The affection may be confounded with syphilitic disease of
the tongue or with papillary epithelioma, but the history of the case,
the resistance to antisyphilitic treatment, and the negative results
from microscopic examination of fragments of tissue removed for the
purpose, serve to establish the diagnosis in cases of doubt. It must
not be forgotten, however, that many cases of epithelioma begin in
chronic glossitis, non-specific as well as syphilitic.
PROGNOSIS.--Though not threatening to life, the prognosis of the
disease itself is bad. It resists treatment, being, in fact, a
complication of some obstinate or intractable gastric or
gastro-intestinal disorder, or an evidence of constitutional dyscrasia.
Cure may be expected in recent cases, following cure of the dyspepsia
or other malady upon which the chronic glossitis may be dependent.
TREATMENT.--Care to cleanse the tongue by washes, douches, or wet
cloths after each meal, in order to remove particles of food which may
have become impacted in the anfractuosities of the organ, is important
in order to avoid additional sources of irritation.
Astringents and caustics of various kinds have been extensively
employed, carefully applied to the floors of the fissures, but it is
very rarely that any benefit ensues. Demarquay[71] reports good results
in one case of dissecting papillary glossitis from biweekly
applications of equal parts of chromic acid and water. Butlin reports
good results from chromic acid (1:10).
[Footnote 71: _Loc. cit._, p. 143.]
Careful attention to the gastro-intestinal functions, and a thorough
change of diet, such as the adoption of the milk cure and the like,
with due attention to bathing and outdoor exercise, comprise the most
rational method of constitutional treatment. Should the secretions of
the mouth give an acid reaction with litmus-paper, alkalies are
strongly indicated, topically and systemically. Avoidance of alcohol in
all forms is often absolutely essential.
Chronic Parenchymatous Glossitis.
The chronic parenchymatous form of glossitis is usually circumscribed.
When diffuse or general it has usually been a sequel of acute
parenchymatous glossitis. It is not a painful disorder, and as a rule
is not associated with constitutional manifestations. The circumscribed
tumefaction usually presents as an induration upon some portion of the
side of the tongue, being most frequently directly or indirectly due to
irritation sustained from a jagged tooth. Ordinary sensibility is much
diminished, and sometimes the sense of taste likewise. Sometimes the
indurated mass is ulcerated superficially. The enlargement of the organ
is not sufficient to keep it outside the mouth. Sometimes, indeed, the
tongue, {368} as a whole, has undergone atrophy, unilateral or
bilateral. Chronic abscess of the tongue sometimes supervenes, chiefly
in scrofulous subjects.
PATHOLOGY AND MORBID ANATOMY.--This consists merely in interstitial
connective-tissue hyperplasia, with atrophy of muscular fibres from
compression.
SYMPTOMS.--In addition to the objective symptoms of induration or
circumscribed tumefaction, the subjective symptoms may be summed up as
general hypersensitiveness to sapid and acrid substances; diminished
tactile sensibility at the part affected; slight stinging sensations
while the parts are at rest; occasional or continuous local pains; and
a sense of impediment in the movements of the tongue in articulation
and even in deglutition.
DIAGNOSIS.--Inspection reveals the swelling, and palpation its
induration. In addition, the adjacent source of irritation, a jagged
tooth or two, is seen. Abscess is recognized by special prominence at
one point of the swelling and by indistinct sense of fluctuation.
Cystic tumor is liable to be mistaken for abscess, but the
exploring-needle will solve the difficulty. Circumscribed induration
may be confounded with tumor or with epithelioma.
PROGNOSIS.--This is good, provided the source of irritation can be
removed or suppressed.
TREATMENT.--The first element in the treatment is the removal or repair
of any offending tooth, and next attention to any underlying malady,
constitutional or local. Weak solutions of iodine locally are said to
be of service. Abscesses require incision and evacuation. Their walls
should be distended with solutions of carbolic acid or be touched with
solutions of iodine, silver nitrate, or cupric sulphate, to promote
reparative inflammation.
Glossanthrax (Carbuncle of the Tongue, Malignant Pustule of the
Tongue).
This is a special variety of gangrenous ulcerative glossitis,
presenting as an integral phenomenon of a disease peculiar to
slaughterers, who become infected from diseased cattle, usually by
means of the knife, which they are sometimes in the habit of holding in
the mouth (Heyfelder and others). It has been described chiefly by
Heyfelder,[72] Duhamel, Chavarrien d'Audebert, Felix Plata, Breschet et
Finot, and Maisonneuve.[73]
[Footnote 72: _Med. Vereins Zeitung_, 1834.]
[Footnote 73: _Des Tumeurs de la Langue_, Paris, 1848, Thèse de
Concours.]
The period of incubation occupies about one day. The tongue then
undergoes rapid tumefaction and becomes the seat of intense pain. The
points of inoculation become hard, covered with vesicles containing
bloody serum, which blacken, rupture, and leave dark, livid, gangrenous
patches of ulceration. Profound cachexia rapidly ensues under typhoid
manifestations, and death may result in less than twenty-four hours,
though usually not until sixty hours. The prognosis, therefore, is of
the gravest character.
The chief treatment consists in thorough cauterization of the
inoculated {369} points by means of the actual cautery, followed by
deep incisions into the body of the tongue if the glossitis be severe.
Ulceration of the Tongue.
Apart from the ulcerations of the tongue incidentally mentioned in the
foregoing pages, there are two forms of ulcer, both of sufficiently
frequent occurrence in ordinary practice to require special
description: these are the tuberculous ulcer and the syphilitic ulcer.
Tuberculous Ulcer of the Tongue.--Tuberculous ulceration of the tongue
occurs in a certain number of cases of advanced tuberculosis of the
lungs or of the lungs and larynx. It has even been asserted to precede
pulmonary tuberculosis. It is most frequently observed upon the upper
surface of one side of the organ, sometimes at the tip, sometimes
farther back, and usually on the same side upon which the disease is
most advanced in the lungs or the larynx. It is often associated with
previous or subsequent tuberculous ulcerations of the palate or of the
pharynx or contiguous structures. It gradually extends, and rarely if
ever heals. It is characterized by a superficial excavation, and by
being covered with a grayish detritus entirely different from the
purulent layers seen on other kinds of ulcers. When of long standing
its base is indurated, and this may give rise at first to suspicion of
squamous-celled carcinoma. Small yellowish elevations are sometimes
observed in the reddened mucous membrane around the ulcer--an
appearance deemed sometimes characteristic of the tuberculous nature of
the lesion (Trélat[74]).
[Footnote 74: _Bull. de l'Acad. de Méd._, 1869, or _Arch. gén. de
Méd._, 1870.]
PATHOLOGY AND MORBID ANATOMY.--Nodular tuberculous infiltration takes
place beneath the mucous membrane, which becomes elevated in small,
semiglobular, yellow protuberances of one or more millimeters in
diameter, around which the mucous membrane is red and swollen. The
epithelium becomes shed without undergoing renewal, and thus a little
point of superficial ulceration remains. When several such points are
sufficiently contiguous they coalesce into a single ulcer of irregular
contour, which gradually spreads without much other change.
Practically, it never heals.
SYMPTOMS.--In addition to the superficial ulceration described, and in
addition to the constitutional and local symptoms of advanced
tuberculosis of the lungs or lungs and larynx, as may be, there are no
special symptoms attending the tuberculous ulcer of the tongue. Saliva
is sometimes secreted in excess, but that is not characteristic. There
is little pain and little impediment to the movements of the tongue
until the disease has advanced.