Apart from the anomalies presented in monsters, there are a few congenital abnormalities of the tongue with which it becomes the accoucheur at least to be familiar, as their presence may interfere materially with the nutrition of the infant, whether nursed or spoon-fed.
CONGENITAL DEFICIENCY OF THE TONGUE.—A considerable portion of the tongue may be wanting anteriorly, comprising, in some instances, the entire free portion of the organ. The stump then presents as a single or a bifid protuberance of variable size. In some instances considerable power of movement exists, and even conservation of taste. Suction and deglutition are both practicable. When the child grows it can speak, though with a certain amount of difficulty. A few cases are on record, however, of ability to speak without any evidence of a tongue above the floor of the mouth.
An instance of lateral deficiency has been observed by Chollet,16 the deficient half being represented merely by the two layers of the lingual mucous membrane, without any intervening muscular substance.
16 Demarquay, Dict. de Méd. et de Chir. prat., xx. p. 130.
BIFID TONGUE, separate investment of the two sides, has been occasionally observed in connection with similar arrest of development in the lower jaw and other organs.
DEFINITION.—An abnormal attachment or adhesion of some portion of the tongue to some portion of the surrounding structures of the mouth.
SYNONYM.—Tongue-tie.
PATHOLOGY AND MORBID ANATOMY.—The ordinary form of tongue-tie consists in an abnormal development of the frenum of the tongue, the anterior vertical portion of the duplicature of mucous membrane which connects the lower surface of the raphé of the tongue with the floor of the mouth. The tongue cannot be extended beyond the lips. Suction is interfered with in some cases. If not remedied spontaneously or by surgical interference, mastication and articulation may become seriously impeded.
Other forms of ankyloglossia, congenital and acquired, possess special interest from surgical points of view mainly.
DIAGNOSIS.—Inspection and digital exploration readily reveal the nature of the restriction in the movements of the tongue and the size of the frenum.
PROGNOSIS.—The prognosis is good, the difficulty being susceptible of relief by division of a portion of the constricting frenum. Accidents have been reported following the operation, the occasional occurrence of which should be borne in mind. These are hemorrhage, which is not dangerous except in the prolonged absence of some one competent to restrain it should it be extreme; and retroversion of the tongue, an accident which has been known to prove fatal by occluding the orifice of the larynx (Petit).
TREATMENT.—Slight cases rarely need operation; but when the movements of the tongue are restricted by a very short and deep frenum its division becomes necessary. The operation is usually performed with scissors, the ranine arteries being protected by means of a fissured plate of metal (Petit), such as has long been used as a handle to the ordinary grooved director of the physician's pocket-case. The cut should be more extensive in the lateral directions of the fold than antero-posteriorly. After-treatment is rarely necessary, unless annoying hemorrhage is produced by movements of suction. Compression between the fingers, maintained for a number of minutes, suffices to restrain the hemorrhage in most instances. When this fails, recourse may be had to cauterization with the point of a heated iron or some other form of actual cautery.
DEFINITION.—Hypertrophy of the tongue.
SYNONYMS.—Megaloglossia, Glossoptosis, Prolapsus linguæ, Lingua propendula, Chronic prolapse of the tongue, Chronic intumescence of the tongue.
HISTORY.—This rare affection has been long known, the first cases on record being in the works of Galen. Other cases have been recorded by Celsus and Avicenna. Among more modern recorders may be mentioned Scaliger (1570), Bartholin (1680), Benedict and Pencer; among recent recorders, Lassus,17 Percy,18 Harris,19 Humphrey,20 Gayraud,21 W. Fairlie Clarke,22 Bryant,23 and the French dictionaries in present process of publication; to all of which the reader is referred for bibliographic, descriptive, and illustrative details.
17 Mémoire de l'Institut National, 18—, an VI. t. i.
18 Dict. Sci. Méd., t. xxvii.
19 Am. Journ. Med. Sci., vol. vii., 1830, p. 17; vol. xx., 1837, p. 15—both illustrated.
20 Trans. Med.-Chir. Soc. London, 1853, p. 113.
21 Thèse de Montpellier, No. 68, 1865.
22 Diseases of the Tongue, London, 1873.
23 "Surgical Affections of the Tongue," Guy's Hosp. Reports, 1883, p. 102 et seq.
ETIOLOGY.—This affection is usually congenital, at least to a certain extent, and augments with the growth of the child. It has been attributed, on apparently insufficient grounds, to injury received during parturition. It is probably intra-uterine in origin. Though encountered in both sexes, the majority of recorded cases have been in females. In summing up these observations, it appears that the affection often attracts little or no attention until dentition is in progress. The hypertrophy begins to augment rapidly during the second or third year of age, or a year or two later in some cases.
The gradual increase of the congenital deformity during infancy has been attributed to hypernutrition from local irritation produced by habits of sucking on the organ, induced, in some subjects, by forcible efforts at suction from a short nipple. Similarly, the rapid augmentation of volume noted as occurring during the period of dentition or a little later has been attributed to hypernutrition excited by irritation suffered by the protruding organ from the lower row of teeth. Cases commencing at this age have been supposed to be due exclusively to tongue-sucking. In some instances, due to this cause apparently, the deformity is associated with idiocy (Lawson24). Convulsions, epileptic seizures, and whooping cough have been regarded by some writers as occasional causes of the deformity. Indeed, idiocy and cretinism are not infrequent co-associates with the deformity (Parrot25). It has been observed likewise in anencephalous monsters (Brissot, idem).
24 Trans. Clin. Soc. London, vol. v. p. 158.
25 Gaz. Méd. Paris, Dec. 10 and 17, 1881; Lond. Med. Record, Mar. 15, 1882, p. 113.
SYMPTOMS, COURSE, DURATION, TERMINATIONS, COMPLICATIONS, AND SEQUELÆ.—The prominent symptom of macroglossia is the enlarged tongue protruding beyond the mouth. The resemblance of the protruding tongue of a child with macroglossia to the tongue hanging from the mouth of a calf gave rise to the name lingua vitulina by which it has sometimes been designated. In some instances, where the enlargement is but moderate, the organ can be retained within the mouth. When bilateral, the enlargement may be symmetrical, or may interest one side of the tongue more than the other. When the enlargement is confined to the free portion of the tongue, it interferes little with respiration and with movements of suction. When occupying the base of the organ, it may seriously embarrass respiration, and even produce suffocation in some instances (Clarke). The mouth being maintained open, saliva dribbles away constantly except during alimentation. Thirst is often very great in consequence of this, and of the desiccation of the tongue and of the walls of the mouth by the unmodified air to which they are continuously exposed. The tongue is usually free from pain.
In some subjects, although the tongue, left to itself, protruded considerably, it has been found quite practicable to maintain it within the cavity of the mouth by means of bandages or other appliances secured to the back and top of the head. These bandages are removed from time to time to give relief from the restraint and to permit food and drink to be taken. Systematic compression, indeed, has been induced in this way in some instances, and has produced considerable diminution in the size of the organ—sufficient to maintain its concealment without the aid of an appliance. When the tongue cannot be retained within the mouth the patient becomes unable to close the jaws. Hence saliva dribbles constantly, save when food or drink is being taken. The protruded portion of the tongue undergoes a livid discoloration, sometimes diffuse, sometimes disseminated. Though sometimes remaining comparatively soft in texture, it usually becomes hard, dry, rough, fissured, ulcerated and sanious, covered with desiccating layers of mucus and epithelium, and marked by indentations made by the edges of the teeth, which sometimes seem almost to strangle it. Mastication, deglutition, and articulation often become very difficult, and respiration also, but less frequently. The lower lip becomes much everted. The larynx and hyoid bone become drawn upward and forward by the weight of the organ. The configuration of the lower jaw undergoes considerable change, and the teeth become pressed out of position. Dislocation of the jaw from this cause has been noticed (Chalk26).
26 Trans. Path. Soc. London, vol. viii. p. 305.
These symptoms undergo aggravation with the growth of the subject, and, while presenting general features of resemblance in all cases, vary considerably in individual instances. Great difficulty is encountered, as a rule, in taking food, and mastication has to be performed very slowly. In some instances mastication can be performed satisfactorily by the molars, owing to a compensatory curvature of the lower jaw, even though the anterior portions of the jaw may remain permanently separated (Harris). Some patients get along by using their fingers to push the bolus far enough back to permit of its deglutition. Some have used a cup with a long tube slightly curved to convey fluids to the back part of the mouth for a similar purpose. Some have been systematically fed by means of a catheter passed through a nasal passage and thus on into the oesophagus. The difficulties in nourishing patients reduce some of them to extreme emaciation.
Notwithstanding all these drawbacks, quite a number of cases are on record where the patients have reached well into adult life before being submitted to radical measures for relief. One patient is recorded as having reached the age of eighty, having worn for some sixty-five years a silver shield to conceal her deformity (Clarke).
PATHOLOGY AND PATHOLOGICAL ANATOMY.—The hypertrophy may involve all the structures of the tongue, but usually implicates the muscular tissue especially (Sédillot, Paget, Bouisson). In a case published by W. Fairlie Clarke it was found on microscopic examination that the papillæ as well as the mucous and submucous tissues were somewhat enlarged and thickened, while the bundles of muscular fibre were slightly coarser than natural. Maas reports a unilateral case of macroglossia in a male child two months of age associated with hyperdevelopment of the entire left side of the body.27 In some instances the blood-vessels and lymphatics are chiefly involved (Virchow, Billroth, Maas), two cases of which have been described by Virchow as cavernous lymphatic tumors.
27 Arch. klin. Chir., p. 413, Bd. xiii. Heft 3.
Hilliard reports28 a congenital case from vicious growth, removed at fourteen months of age. Microscopic sections showed the large lacunæ filled with corpuscles, blood-pigment in different stages of degeneration, and the papillæ much hypertrophied. Winiwarter29 reports a congenital macroglossia associated with congenital cysts of the neck.
28 Brit. Med. Journ., Nov. 26, 1870, p. 591.
29 Arch. klin. Chir., 1874, Bd. xvi. Heft 3.
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.
| FIG. 14. |
| Chronic Intumescence of the Tongue |
| Chronic Intumescence of the Tongue (Harris). |
| FIG. 15. |
| Chronic Intumescence of the Tongue |
| Hypertrophy of the Tongue (Harris), before operation and after. A, odontolith. |
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. Clanny30 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. Frederici31 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,32 and likewise in a case of Gies,33 requiring subsequent excision of the exuberant portions. Operations with the ligature, though sometimes successful (Fergusson,34 Hodgson35), may be followed by fatal septicæmia during the slough (Liston36), or, failing to strangulate the tongue sufficiently, may require the application of the knife, after all, to affect the separation (Harris37).
30 Edinb. Med. and Surg. Journ., 1805, vol. i., cited by Clarke.
31 Arch. gén. de Méd., 1844; Edinb. Med. and Surg. Journ., p. 528, vol. lxiv., 1845.
32 Edinb. Med. Journ., 1857, vol. ii. p. 1057.
33 Arch. klin. Chir., 1873, p. 640.
34 Practical Surgery, London, 5th ed., p. 518.
35 Trans. Med.-Chir. Soc. London, 1858, p. 129.
36 Elements of Surgery, p. 334, Philada., 1842.
37 Am. Journ. Med. Sci., vol. vii. p. 17.
Excision with the incandescent loop of the galvano-cautery seems to be the most suitable procedure. Valerani38 operated in this manner without the loss of a drop of blood upon a congenital macroglossia in a child seven months of age. Maas39 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 begins40—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'Sullivan41 excised the hypertrophied tongue of a female sixty-five years of age.
38 Giornale della Reale Accademia di Turino, fasc. 1518; London Med. Record, Sept. 15, 1876, p. 408.
39 Loc. cit.
40 Lancet, March 30, 1872, p. 432.
41 Dublin Journ. Med. Sci., Aug., 1875, p. 178.
Ignipuncture with the thermo-cautery of Paquelin has been successfully used of late by Helferich and by von Bruns of Tübingen.42 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.
42 Centbl. f. Chir.; Med. Times and Gaz., Sept. 23, 1883.
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 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.
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 Mussy43).
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 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. Hulke44 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).
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. Sangster45 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 (81/3 per cent.) was there positive proof or strong evidence of syphilis; 30 per cent. of the whole number eventuated in epithelioma.
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.
46 Lancet, March 11, 1865; Clarke, op. cit., p. 88.
47 Dub. Journ. Med. Sci., May 1, 1876, p. 401, illustrated.
48 Lancet, Nov. 22, 1879, p. 764.
49 Brit. Med. Journ., Oct. 7, 1882, p. 683.
50 Gaz. hebd., June 22, 1883; Med. News, Aug. 11, 1883, p. 151.
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.
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 others. Outside of French literature, little had been written of it until very recently.
51 Article "Tongue," Encyclopedia of Anatomy and Physiology, London, 1849-52, vol. iv. pp. 1159, 1160.
52 Gaz. hebd., 1869, No. 14, p. 221.
53 Gaz. des Hôp., June 29, 1875.
54 Union Méd., March 20, 1877.
55 De la Langue noire [Glossophytie], Paris, 1878, 8vo, p. 38, illustrated.
56 Gaz. Méd., Strasbourg, 1879.
57 Bull. Méd. du Nord, 1883.
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 Cohen59 in a negro child the subject of congenital syphilis. Mr. George Stoker60 and G. Y. Broatch61 have each reported a case of long duration occurring in a painter.
59 The Polyclinic, Philada., July, 1884, p. 10.
60 Brit. Med. Journ., March 29, 1884, p. 602—said to be first case recorded in England.
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 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.
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.