Part 53

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.

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 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 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, and likewise in a case of Gies, requiring subsequent excision of the exuberant portions. Operations with the ligature, though sometimes successful (Fergusson, Hodgson), may be followed by fatal septicæmia during the slough (Liston), or, failing to strangulate the tongue sufficiently, may require the application of the knife, after all, to affect the separation (Harris).

Excision with the incandescent loop of the galvano-cautery seems to be the most suitable procedure. Valerani operated in this manner without the loss of a drop of blood upon a congenital macroglossia in a child seven months of age. Maas 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--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 excised the hypertrophied tongue of a female sixty-five years of age.

Ignipuncture with the thermo-cautery of Paquelin has been successfully used of late by Helferich and by von Bruns of Tübingen. 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.

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.

ETIOLOGY.--Predisposing and Exciting Causes.--It is rarely idiopathic, 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).

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 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).

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 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.

Vesicular glossitis, usually unilateral and most frequently right-sided, has been described by Paget, Stoker, Barker, Hill, and De Mussy, and doubtless by others.

{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.