Part 55

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). 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.

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 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.

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 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).

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.