Part 56

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, Duhamel, Chavarrien d'Audebert, Felix Plata, Breschet et Finot, and Maisonneuve.

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).

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.

DIAGNOSIS.--The presence in a tuberculous subject of a unilateral, irregular ulcer of the tongue surmounted with grayish detritus and surrounded by reddened edges, should suffice for the recognition of its presumptive tuberculous character. It is most difficult perhaps to differentiate from a small ulcerated squamous-celled carcinoma, and the two indeed sometimes coexist, rendering the discrimination extremely difficult until the advanced progress of the carcinoma places the diagnosis beyond doubt.

{370} In the early stages, however, it is distinguished by lack of the peculiar lancinating pains of carcinoma, which, however, are not invariably attendant, and by lack of secondary involvements of the cervical lymphatic glands. At all times it should be distinguishable from the carcinomatous ulcer by lack of the fungus-like appearance of the bed of the ulcer which is usual in carcinoma.

From syphilitic ulcer it is distinguishable by the history of the case, its tendency to be unilateral, and its failure to respond to antisyphilitic treatment. Syphilitic ulceration of the tongue may represent the primary, the secondary, or the tertiary manifestation of the specific disease. The former will not be discussed in this connection.

Secondary ulcers occur on the upper surface of the tongue, most frequently at the anterior portion, as fissures, usually longitudinal, the floors of which are ulcerated. They occur likewise at the sides, tip, and even lower surface of the organ. They are often associated with secondary ulceration in the mucous membrane of some portion of the mouth. They are quite painful, especially to the contact of pungent articles of food. Some ulcers occur as simple superficial excoriations at some portion of the edge or tip of the tongue, giving little evidence of any specific character.

Tertiary ulcers are usually sequelæ of gummata. They are much deeper than secondary ulcers, sanious at bottom, often serpiginous in configuration, and apt to extend in depth as well as in superficies, sometimes penetrating through and through the organ. They are most frequent in the very central portion of the tongue, or are symmetrically disposed on either side of it.

PROGNOSIS.--The prognosis of tuberculous ulceration is bad, both as regards tongue and patient.

TREATMENT.--The only topical treatment offering any prospect of local cure is the bodily destruction of the ulcer and the surrounding tissue with caustics, the best of which are the incandescent metals, or else the excision, with the incandescent knife, of a portion of the tongue comprising all the affected tissue. In the former case the tuberculous process often reappears about the cicatrix; in the latter, at some more distant point.

Tincture of iodine locally, detergent washes, and the like, often secure a certain amount of comfort as palliatives. The same indications prevail as in simple chronic glossitis, superficial and deep-seated. Iodoform locally is of benefit, inasmuch as it relieves pain and reduces collateral inflammation, but it is powerless to arrest the onward march of the ulcerative process.

Hemorrhage from the Mouth.

DEFINITION.--A loss of blood from the mouth.

SYNONYM.--Stomatorrhagia.

ETIOLOGY.--Hemorrhage from the mouth is usually a symptom of some disease or injury of the mouth, tongue, gums, palate, pharynx, or nose. It may, however, occur as one of the phenomena of scorbutus or of hæmophilia. It is said to occur occasionally as a vicarious {371} menstruation. It may be slight, so as barely to tinge the saliva, or it may be profuse enough to terminate fatally. Between these extremes there is an infinity of gradations. As a result of disease it may be caused by simple hyperæmia of the mucous membrane, by rupture of dilated blood-vessels, by ulceration, by gangrene. As a result of injury it may arise from wounds of various kinds, accidental or self-inflicted.

The gums are the most frequent source of slight hemorrhage from the mouth. The pharynx, probably, is the next most frequent seat. Hemorrhage from the tongue, cheeks, lips, and palate is usually traumatic or the result of ulceration.