DISEASES OF THE TONGUE PLATE I. Fig. 1. Vesicular eruption on the tip of the tongue of an intemperate man. Fig. 2. Indentations produced by the teeth in the tongue of a woman, 60 years of age. Fig. 3. Soreness and excoriation of the tongue in a youth, 17 years old. Cause uncertain. ^DISEASES OF THE TONGUE BY HENRY T. SUTLIN, F.R.C.S., D.C.L. SURGEON TO ST. BARTHOLOMEW'S HOSPITAL ; FORMERLY ERASMUS WILSON PROFESSOR OF PATHOLOGY AND HUNTERIAN PROFESSOR OF SURGERY AT THE ROYAL COLLEGE OF SURGEONS AND WALTER G. SPENCER, M.S., M.B. (Lond.) F.K.C.S. SURGEON TO THE WESTMINSTER HOSPITAL, AND IN CHARGE OF THE DEPARTMENT FOR DISEASES OF THE NOSE AND THROAT ; FORMERLY ERASMUS WILSON PROFESSOR OF PATHOLOGY AT THE ROYAL COLLEGE OF SURGEONS ILLUSTRATED WITH EIGHT CHROMO-LITHOGRAPHS AND THIRTY-SIX ENGRAVINGS CASSELL AND COMPANY, LIMITED LONDON; PARIS, NEW YORK $ MELBOURNE 1900 ALL EIGHTS EE9EKVED First Edition .!///# 1885. Reprinted 1890. -Veto Enlarged Edition 1900. BCTUN, H. T. Maladies de la Langue. Traduit Je 1' Anglais par Douglas Aigie. Paris. I V M*. Lecrosnier et Babe. 424 pp. S\o. BUTLIN, H. T. Kraukheiten der Zunge. Deutsch bearbeltet und lierausgegabin von Julius Beregszaszy. Wien, 1887. V?. Braumiiller. 402 pp., 8 pi., S\o. PREFACE. EVER since I have been a member of the staff of St. Bartholomew's Hospital, I have used the opportunities which the large out-patient practice of the Hospital has given me of collecting notes and drawings of diseases of the tongue. I did not do so at first with any definite intention of publishing them, and certainly not with any intention of writing a work on Diseases of the Tongue. When, however, I was asked by Messrs. Cassell and Company to undertake this task, I accepted, on account of the opportunity it afforded me of bringing my material before the profession much more thoroughly than would probably have been the case had I published the book independently. In addition to my own cases, I have had the advantage of observing many cases under the care of my colleagues in the Hospital, and have even been permitted to have drawings made of those which I desired. Some of these drawings have been lithographed ; but the very large majority of the illustrations have been taken from cases which have been under my own care. When Sir James Paget learned what work I was engaged in, he was good enough to interest himself in it so far as to look out for me his manuscript notes of several cases, among them one of tuberculous ulcer of the tongue taken about thirty years ago. I have to thank Mr. Godart for the care which he has vi PREFACE. taken in rendering so truthfully the various diseased con- ditions, sometimes, indeed, in circumstances but little favourable to artistic skill. Now that the book is passing out of my hands, I am oppressed by the feeling that, in spite of the labour which has been bestowed on it and of the exceptional advantages I have in many ways enjoyed, it does not nearly reach the ideal I had formed for it. HENRY T. BUTLIN. Queen Anne Street, V., April, 188-5. PKEFACE TO THE SECOND EDITION. WHEN, not long after the appearance of this book, I received notice from the Publishers that they would be obliged if I would prepare a second edition, I was on a holiday on the Continent, and could not undertake the revision until my return home. The book was therefore reprinted with- out addition or alteration. Some long time has elapsed ere I summoned the courage to undertake the labour of a new edition ; nor should I have done so now had I not found a colleague in Mr. Walter Spencer, who is equally acceptable to Messrs. Cassell and myself. Owing to his efforts, the present work forms a more complete treatise on the diseases of the tongue than the clinical manual which, in the first instance, I was only able to prepare. The encyclopaedic method has been to some extent main- tained, on account of its convenience to the reader ; but, in addition, each disease is treated in a more systematic manner. Various additions have been made, such as the chapter on the anatomy of the tongue ; for this, and for much of the later pathology, Mr. Spencer is responsible. On many points relating to clinical occurrences, particularly on the manner in which cancer first appears on the tongue ; and on ques- tions of operative surgery for malignant disease, the experi- ence I have acquired during the last fifteen years enables me to speak with far greater authority than I ventured to do in 1885. Even now there are many matters, such as viii PREFACE TO THE SECOND EDITION. the relation of cancer of the tongue to the lymphatic glands, on which a great deal more experience and research are needed. Imperfect as we know the book to be, Mr. Spencer and I trust that it may be useful to all those members of our profession who need help in the diagnosis and treatment of the more common diseases of the tongue ; or who happen to meet, for the first time, with one of the rarer affections, and would know where and under what circumstances similar cases have been seen before. HENRY T. BUTLIN. April, 1900. CONTENTS. CHAPTER I. THE ANATOMY OP THE TONGUE ..... . .1 CHAPTER II. THE CONGENITAL DEFECTS OF THE TONGUE . . . . 2(i CHAPTER III. ACCIDENTS TO THE TONGUE AND ACQUIRED DEFORMITIES . . 35) CHAPTER IV. SEMEIOLOGY ; DISCOLORATIONS . . . . . .53 CHAPTER V. ACUTE PARENCHYMATOUS Gi/issixis; ACUTE ABSCESS; GANGRENE . (56 CHAPTER VI. ACUTE SUPERFICIAL GLOSSITIS : . . . . .79 CHAPTER VII. SUBACUTE AND CHRONIC SUPERFICIAL GLOSSITIS . . .94 CHAPTER VIII. CHRONIC SUPERFICIAL GLOSSITIS . . . . . .114 CHAPTER IX. ON VARIOUS MORBID CONDITIONS ..... 149 CHAPTER X. INI KI'TIVE AND PARASITIC DISEASES OF THE TONGUE. . 170 x CONTENTS. CHAPTER XL SYPHILIS OP THE TONGUE ....... 188 CHAPTER XII. TUMOURS AND CYSTS OP THE Mucous AND SALIVARY GLANDS ; SALIVARY CALCULI . . . . . . .225 CHAPTER XIII. CYSTS OP THE TONGUE ....... 239 CHAPTER XIV. DISEASES OP THE BASE OP THE TONGUE; THYREOGLOSSAL CYSTS AND TUMOURS . . . . . . . . 248 CHAPTER XV. HYPERTROPHY OP THE TONGUE, OR MACROGLOSSIA . . . 264 CHAPTER XVI. INNOCENT TUMOURS ........ 280 CHAPTER XVII. MALIGNANT CONNECTIVE-TISSUE TUMOURS, OR SARCOMAS . . 298 CHAPTER XVIII. CARCINOMA . . . . . . . . 309 CHAPTER XIX. EARLY SURGERY OP THE TONGUE ... . 346 CHAPTER XX. EXCISION OP THE TONGUE ....... 367 CHAPTER XXI. QUESTIONS CONNECTED WITH OPERATIONS .... 390 CHAPTER XXII. NERVOUS AFFECTIONS OP THE TONGUE . . . 410 AUTHORITIES . . . . . . . . i r> INDEX . . . 469 LIST OF ILLUSTRATIONS. PAGE Development of the Tongue ....... 3 Diagram of Thyreoglossal Tract . ... 5 Diagram of One Side of the Floor of the Mouth .... 8 Orifices of Salivary Ducts . . .... 9 Transverse Section of the Tongue . ... 17 Under Surface of the Tip of the Tongue . . . . .18 Lymphatic Glands below the Jaw and in the Xeck . . .22 Chronic Superficial Glossitis . . . . . . .117 Smooth Tongue resulting from Chronic Superficial Glossitis . .142 Excision of a Chronic Horseshoe -shaped Ulcer .... 158 Excision of a Chronic Ulcer on the Side of the Tongue . . 159 Tuberculous Disease of the Tongue ...... 171 Leprosy of the Tongue ....... 184 Salivary Gland Tumour ....... 227 Diagram of Situation of Dcrmoid Cysts . . . . .241 Swollen Lingual Tonsil . . 249 Thyreoglossal Tumour ....... 252 Ciliated Epithelium from a Thyreoglossal Cyst .... 260 Macroglossia : Hypertrophy of Epithelium and Sclerosis of Muscle . 266 Macroglossia : Superficial Lymph Cyst ..... 267 Macroglossia : Lymphadenomatous Material replacing Muscle . . 267 A Case of Macroglossia ....... 270 Jaws Deformed by Macroglossia . . . . . .271 Papilloma . ... 295 Warty Epithelioma . ... 319 Epithelioma : Columns of Epithelial Cells Growing Downward . . 325 Epithelioma : Growing Portions of Epithelial Columns . . . 326 Epitheliomatous Nest Cells . ..... 327 Epithelioma rapidly Growing without forming Nest Cells . . 328 Fibrous or Scirrhous Epithelioma ...... 329 Epithelioma with Small Cell Infiltration ..... 330 Early Epitheliomatous Infection of Lymphatic Gland . . . 332 Regnoli's Submental Incision ...... 358 Mouth Opened by Gag, Cheek Retracted, and Tongue Drawn Out . 369 Incision for Submaxillary or Extra-buccal Operation . . . 382 Hemiatrophy of the Tongue . . . . . . . 426 LIST OF COLOURED PLATES. PLATE I. Fig. 1. Vesicular eruption on the tip of the tongue of an intemperate man. Fig. 2. Indentations produced by the teeth in the tongue of a woman, 60 years of age. Fig. 3. Soreness and excoriation of the tongue in a youth, 17 years old. Cause uncertain. PLATE II. Fig. 1. Fissured tongue from a man, 34 years old, the subject of tertiary syphilis. Fie. 2. Great disfigurement of the tongue, produced by tertiary syphilis, in a woman. Fig. 3. Chronic ulcer of the tongue in a man. surrounded by contracted tis-ues. PLATE III. Fig. 1. Ulcer due to the rubbing of bad teeth, with sloughy surface and slightly raised red base. Fig. 2. Tuberculous ulcer of tip in a womnn, 45 years old. Fig. 3. Lupus of fore part of tongue in a woman, 23 years old, with lupus of face and nose. The mouth is opened, the lower lip is everted and the seat of a sloughy ulcer, and the tongue, which cannot be protruded, is seen through the slightly parted lips. PLATE IV. Fig. 1. Mucous patch, deeply grooved and ulcerated. The yellower tongue- like portion towards the dorsum shows the manner and area over which it had extended in the course of a week. Fig. 2. Gummatous ulcer of border in a man, aged 25. The slough has not been completely removed. Fig. 3. Large cleft or fissure-like cavity produced by the breaking of gummata in the tongue of a man, aged 39 years. I he cavity is repre- sented as it appeared when its sides were separated by the fingers. PLATE V. Fig. 1. Leucoma in a man, 41 years old, of about two years' duration. Fig. 2. Leucoma in a man, 34 years old. with abrasions and raw areas along the borders, due to an acute attack of inflammation in an old diseased tongue. Fig. 3. Leucoma covering the entire dorsum and borders of the tongue, with a little warty growth not yet become cancerous. PLATE VI. Fig. 1. Wandering rash in a boy, aged 9 nine years. Fig. 2. Mucous patches in secondary syphilis. Fig. 3. Mucous patches on the under aspect of the tip of the tongue in secondary syphilis. PLATE VII. Fig. 1. Tertiary syphilitic plaque of dorsum of tongue in a man, aged 30 years. Two gummata on right border commencing to shrink. Fig. 2. Lymphangioma of the whole thickness of the anterior half of the tongue in a boy, 7 years old. Fig. 3. Carcinoma of the left border of the tongue of a man, aged 40. PLATE VIII. Fig. 1. Warty cancerous growth of the tongue of an old man, which had been leucomatous for many years. The warty growth had not been noticed longer than a few weeks. Fig. 2. Protuberant carcinoma of the tongue of a man, with a slough of the central part. Fig. :5.Ul( crated and fissured caicinoma in a man, aged 52. under the care of Mr. T. Smith. The tongue lies within the opened mouth, and cannot be protruded. DISEASES OF THE TONGUE. CHAPTER I. THE AXATOMY OF THE TONGUE. Comparative Anatomy aud Embryology The Thyreoglossal Tract The Mucous and Salivary Glands The Middle Line of the Tongue The Epithelial Surface The Lingual Tonsil The Arteries and Veins The Lymphatics and Lymphatic Glands The Xerves. A FULL description of the anatomy and embryology of the tongue is to be found in the text-books devoted to those subjects. It will be of service, however, in this chapter to note the points which are of special interest in relation to the pathology and surgery of the tongue. 1. Comparative Anatomy and Embryology. The tongue is divided into a lingual muscular organ and a sublingual portion characterised by mucous and salivary glands, lying upon the muscles connecting the lower jaw and hyoid bone. It is the glandular under- tongue which is alone found in the lower vertebrates. In fishes the tongue is represented by the mucous membrane covering the body of the hyoid bon'o, which is thrown into folds. By down- growths of the mucous membrane simple tubular or com- pound tubular glands are produced. A section of the tongue, for instance, of a salamander shows that it is covered with simple tubular glands resembling those lining the stomach and intestine. In a large animal, like the crocodile, there is no projecting muscular tongue, but the surface is covered with pits, the openings of these glands. As offshoots from the muscles joining the lower jaw and hyoid bone in the higher vertebrates arise the lingual muscles. The muscular substance makes its way up from behind at the 2 DISEASES OF THE TONGUE. base and grows forwards, pushing aside the glandular sub- stance, which thus comes to lie below and to the side. At the same time, most of the latter develops into glands of the compound type. The simple tubular glands are like those lining the stomach and intestine, and the compound submaxillary and other gland masses may be compared to the pancreas. In both cases the formation is from the same layer of the blastoderm, viz. the hypoblast or endoderm. Some of the simple glands remain on the dorsum at the base and in front of the junction of the palatoglossal fold, where the orifices are to be seen in large monkeys, such as baboons. (Flower.) The nerve, which in lower vertebrates supplies the muscles of the front of the neck, rightly called " hypo- glossal," is carried up with the muscular development and becomes the motor nerve of the tongue proper. The nerve of the glands and floor of the mouth, the lingual nerve, becomes the sensory nerve of the fore part of the tongue, whilst the sensory nerve of the fauces, the glosso- pharyngeal, is distributed to the hinder third. The lingual artery, originally carrying blood to the muscles of the floor of the mouth and the glands, continues in the higher verte- brates to rim below most of the muscular substance, but gives off upwards towards the surface numerous branches. The development of the tongue and neighbouring structures in the embryo is connected with the branchial arches and clefts or grooves (Fig. 1.) as set forth in the following table: 1st branchial arch : The lower jaw, the ear ossicles, the tensor palati, the third division of the fifth nerve. 1st branchial clelt : The cavities of the outer and middle ear, including the Eustacbian tube. 1st and 2nd branchial arches, ventrally or anteriorly : The body of the tongue, the middle lobe of the thyroid. 2nd branchial arch : Styloid process, stylohyoid ligament, Jesser cornu of hyoid bone, stjloglossus, levator palati, anterior pillar of fauces, facial nerve (chorda tympani). 2nd branchial cleft : Fossse in the neighbourhood of the tonsil, and the tonsil. 2nd and 3rd branchial arches, ventrally or anteriorly : Base of the tongue, muscles of the floor of the mouth, body of the hyoid bone, epiglottis and ary-epiglottic folds and neighbouring f<.-;r. DEVELOPMENT OF THE TONGUE. 3 thyreoglossal tract, including the inner part of the lateral lobes of the thyroid gland. 3rd branchial arch : Great cornu of hyoid bone, hyoglossus muscle, stylopharyngeus, superior constrictor, glosso-epiglottic folds, internal carotid, glossopharyngeal nerve. 3rd branchial cleft : Thymus. 4th branchial arch : The thyroid cartilage and middle and inferior pharyngeal constrictors, superior laryngeal nerve. 4th branchial cleft : Lateral lobes of the thyroid gland. Tii. Fig. 1. DEVELOPMENT OF THE TONGUE. Drawing of a Sagittal Section through the head of a human embryo. Copied, by the kind permission of Prof. His, Iroin his paper on the Tractus Tliyreoglossus. R. I. Rfcessus infuiulilmli. Hp. Hypophysis. B. O. Recessus opticus. F. C. Foramen cajcum. Tr. Tliy. (1),(2), (3). Tractus Thyri-o-lossns. T. Tuberculum impar. E. Tubercle forming base of tongue ami epiglottis. H. Hyoid bone. P. A. Plica aryepiglottica. L. Larynx. P. Pleural cavity. Th. Thymus. Lj. Lip and lower jaw. The development of the tongue in the human embryo has been fully described by Professor His in his " Anatomy of Human Embryos," and an illustration of his is here re- produced. Below the first branchial or inferior maxillary, or mandibular arch, there is, anteriorly from the erect or human standpoint, ventrally in the prone or animal position, a thickening of mesoblast causing a fusion of the arches and irrooves to form a " mesobranchial area." Just below 4 DISEASES OF THE TONGUE. the lower jaw there arises a projection into the mouth, the " tuberculum impar," which by further growth gives origin to the portion of the tongue in front of the circum- vallate papill.e, or lingual V. In the " mesobranchial area" opposite the ends of the second and third branchial arches arises another tubercle to form the base of the tongue and epiglottis. This tubercle, forming the base, grows a little forwards on each side, so as to become forked, and the line of fusion with the "tuberculum impar" in front has an angular form, the lingual V, as marked by the circuinvallate papillae. Between the two is the thyreoglossal tract and the foramen caecum. 2. The Thyreoglossal Tract. This is the name used by His. The word " duct," thyreo- glossal or lingual, is often employed, but there is no evidence of the existence of a duct in any living animal either during embryonic or later life. In man there is at the end of the tract on the dorsum of the tongue, in the angle of the V, a small pit about 1 cm. deep, the foramen ciecum. It was described by Morgagni, and later by Bochdalek. The foramen caecum seems not to be found in other mammals, not even in monkeys, but to be peculiar to man. As to the depth of the foramen caecum beyond 1 cm. a sinus has been traced by dissection as far as the hyoid bone (Royal College of Surgeons' Museum, Phy- siological Series, 1526 B.), but there is much doubt whether such dissections may not have been artificial. The thyreoglossal tract (Fig. 2) marks the line connecting the floor of the mouth with the isthmus and neighbouring portions of the thyroid gland, a separation between the two having taken place during the elongation of the neck of the embryo. The line of the tract runs from the fora- men caecum downwards in the raphe between the genio- hyoglossi muscles to the hyoid bone. It is intimately connected with the body of the hyoid bone, also with the periosteum in front and with the thyrohyoid bursa behind. Below the mylohyoid muscle the tract is to be traced from its close connection with the lower and posterior edge of the hyoid bone downwards in front of the thyro- TIIYREOGLOSSAL TRACT. 5 hyoid ligament to the pyramidal lobe of the thyroid gland beneath the raphe uniting the sternohyoid muscles. The pyramidal lobe is originally double, connected with the isthmus and lateral lobe of either side. Exceptionally it Ghg. Fig. 2. DIAGRAM OF THYBEOOLOSSAL TRACT AND ITS RELATIONS. F. C. Foramen cwcum. Tr. Thy. (1) Thyreog-lossal tract above hyoid bone. Tr. Thy. (2) Thyreoglossal tract in front of thyrohyoidligainent. Tr. Thy. (3) Pyramidal lobe. Thy. I. Isthmus of thyroid gland. Ghg. Geniohyoglossus muscle. Gh. Geniohyoid muscle. Myl. Mylohyoid muscle. L. T. Lingual tonsil. H. Hyoid bone. Thy. B. Thyrohyoid bursa. Thy. L. Thyrohyoid ligament Sth. R. Sternohyoid raphe". E. Epiglottis. Thy. C. Thyroid cartilage. Cr. C. Cricoid cartilage. Cr. L. Cricoid ligament. remains so, usually it becomes single and united with the isthmus and with one or other lobe. As has been said, the description of the thyreoglossal tract was made by His from observations on young human embryos. They have been proved of great importance as explaining certain cysts and tumours at the base of the tongue. The state- ments of His were contested by Kanthack on the ground 6 DISEASES OF THE TONGUE. that he had not found evidences of the existence of this thyreoglossal tract in a hundred adult tongues and in sixty foetal and children's tongues. But Kanthack's researches were not to the point, and certainly did not invalidate the observations of His. Doubtless, after early embryonic life all traces of the tract do, as a rule, disappear, except the foramen caecum at one end and the pyramidal lobe project- ing up from the thyroid isthmus at the other. But, as will be described subsequently in Chapter XIV., there are found along the course of this tract cysts lined with ciliated epithelium, masses of thyroid gland tissue forming accessory thyroids, noted on post-mortem dissection, or actual tumours seen during life, some solid, others secondary cysts due to the degeneration of thyroid adenomata. Accessory thyroid masses are more easily found during post-mortem dissec- tions in countries where enlargements of the thyroid gland are common, hence the frequency noted by Streckeisen at Basle. Numerous microscopical examinations by different observers have placed it beyond question that these tumours consist of thyroid gland tissue. Not only is it thyroid gland tissue anatomically, but there is complete proof that it is physiologically thyroid gland ; for in several cases, as will be mentioned later, a thyroid tumour has been removed from the base of the tongue in the position of the foramen caecum, after which the patient suffered from myxoedema, or cachexia strurnipriva, no thyroid gland being perceptible to pal- pation in the ordinary position. This operative myxoedema had to be relieved by administering thyroid gland tabloids. The original lining of the foregut in the embryo formed from the endoderm or hypoblast is ciliated stratified epithe- lium. This undergoes a transition in older embryos of higher vertebrates into the stratified squamous epithelium of the mouth, pharynx and oesophagus. But congenital oesophageal cysts are lined with the ciliated stratified epithelium which lined the oesophagus when the diverticulum forming the cyst took place. So also the ciliated cysts found in the course of the thyreoglossal tract have derived their epithelium from the endoderm in the position of the foramen caecum, and may be found as low as the thyroid isthmus. There SUBMAX1LLARY SALIVARY GLAND. 7 is no sign of any connection of such cysts with the larynx or trachea. (Neumann.) 3. The Mucous and Salivary Glands. Of the glandular masses opening into the mouth, and arising as outgrowths from the endoderm or hypoblast, four open below the tongue (Fig. 3), but the simple mucous glands at the base behind the circurnvallate papillre, and those in the region of the foliate papilla? in front of the junction of the palato-glossal fold with the tongue, must not be forgotten in connection with certain tumours. (a) The Submaxillary Salivary Gland lies partly on the outer side of the mylohyoid, enclosed by a pouch of fascia which it has pushed out before it in the course of its develop- ment, and which forms its special capsule. The rest of the gland with Wharton's duct is behind and on the inner side of the mylohyoid muscle, immediately beneath the mucous membrane, and communicates through the mouth of the pouch-like capsule with the outer part of the gland. The minor ducts from the various lobules unite into the common duct of Wharton, which runs along the floor of the mouth, to open on the papilla to one side of the framum (Fig. 4). Subject to much variation it receives near its end one or more ducts from the sublingual gland. The formation of retention cysts or ranulse, the develop- ment of a calculus, or the growth of a tumour, gives rise to different clinical manifestations, according to the parts in- volved, whether this be the main duct or the buccal portion of the gland immediately beneath the mucous membrane of the floor of the mouth internal to the mylohyoid muscle, or the part of the gland outside the mylohyoid below the angle of the jaw. The external portion of the subm axillary gland covers a large part of the digastric triangle. The facial artery runs in a groove formed in the capsule, but only its branches enter the gland. This portion of the gland is also intimately connected with neighbouring lymphatic glands. The outer surface ot the snbmaxillary gland, including its capsule, is lobulated and lymphatic gland masses are found closely adherent to the capsule in the folds between the lobules. But turther microscopic observations have shown that 8 DISEASES OF Till': TONGUE. lymphadenoid masses are met with inside the capsule and between the lobules and alveoli of the gland itself, which may become infiltrated by cancer. In old patients masses of fat take the place of some of the lobules. The metamorphosis of glandular substance into lymphadenoid material and into fat is a well-known feature of the thymus. No lymph- Myl. Fig. 3. DIAGRAM OF ONE SIDE OF THE FLOOE OF THE MOUTH AFTEE CUTTING AWAY THE TONGUE. Sm. G. Submaxillary gland. Sm. D. Siibmaxillary or Wharton's duct. 81. G. Sublingual gland. SI. D. Sublingual ducts, ducts of Rivinus. I. G. Incisive gland. I. G. D. Incisive < gland duct. L. L. Lower lip. L. J. Lower jaw. Ghg. Cut-end of geniohyoglossus muscle. Gh. Geniohyoid. Myl. Myloliyoid. Pg. Palatoglossus. Stg. Styloglossus. E. Epiglottis. H. Hyoid bone. adenoid masses have been observed in the buccal portion of the gland, nor in connection with the sublingual gland. (b) The Sublingual Gland. It consists of lobules of alveoli much more loosely connected than those of the Submaxillary gland, and is not enclosed by any capsule. It lies along the floor of the mouth superficial to and beneath Wharton's duct on the upper surface of the mylohyoid muscle (Fig. 3). It has many ducts, which either open freely on the surface along the ridge running up to the frsenum (Fig. 4) or join Whar- ton's duct. Sometimes the sublingual ducts first collect into a common one, which may have either of the two endings above noted. Retention cysts, calculi, rarely tumours, affect the gland and its ducts. They form in the floor of the mouth GLANDS OF RLAXDJN. 9 towards .the anterior end of the tongue. Wharton's duct may be free, as seen by exciting salivary secretion and watching for a flow from the papilla, also by probing the duct. But when the posterior part of the sublingual gland is affected Wharton's duct may be compressed from the outside. The sublingual gland lies above the mylohyoid muscle, but a B.G.D. 8m. D. Fig. 4. OEIFICES OF SALIVARY DUCTS, AFTER MERKEL. B.G.D. Blandin's gland ducts. 81. D. Sublingnal ducts. Sm. D. Salivary papilla with orifice of submaxillary or Whartou's duct. careful dissection of the under-surface of the muscle has shown lobules of the sublingual gland herniating between the muscular fibres and appearing on the under-surface of the mylohyoid. Such a hernia of a sublingual lobule has been held to account for the position of certain ranulre, as will be afterwards described. (e) The Glands of Blandin. In 1823 Blandin described underneath the tip of the tongue, on each side of the middle line, a gland the size and shape of an almond, having vessels and nerves, but quite distinct from the sublingual gland. 10 DISEASES OF THE TONGUE. The gland is exposed by reflecting the mucous membrane, and in contact with it above are the muscular fibres of the lingualis and styloglossus. If the tip of the tongue be curled up and the surface dried, pits marking the opening of the ducts, two or more on each side, may be seen (Fig. 4). Cysts, calculi, and tumours also form in this gland. Nuhn repeated Blandin's description in 1845. (d) The Incisive Gland. Merkel says that in front of the salivary caruncle, lying immediately upon the periosteum of the lower jaw, and only a little below the neck of the central incisor tooth, is a small group of glands (Fig. 3), which are constant in occurrence, as described by Suzanne, and are best named glandula incisiva. There are also other small mucous glands about the openings of the submaxillary ducts. Merkel agrees with others in finding no evidence for the existence of Fleischmann's bursa, which had been alleged to occur in this position. One may, therefore, dismiss it without further mention, and attribute ranulae in this position in front of the sublingual to the group of incisive glands. 4. The Middle Line of the Tongue. In connection with the origin of epidermal or dermoid cysts, also of other and rarer tumours, it is more than probable that information must be sought for from com- parative anatomy and embryology. Nevertheless, at present, not much light on the pathology of such cysts and tumours can be got in this way. These epidermal cysts have no connection with the cysts of the thyreoglossal tract, although the two may have been previously classed together. The thyreoglossal cysts originate from endoderm, and are lined by ciliated epithelium, or have thyroid gland tissue in their wall. The epidermal cysts have all the characters of being derived from detached pieces of epiderm, and may show a lining simply of epidermis, or of it along with appendages of the skin, sebaceous glands and hair, with a more or less thick wall resembling the dermis. At an extremely early age of the human embryo, before the end of the second week, the epiderm has enclosed the foregut and met in the middle line. Therefore, if it be remnants from this epidermal union which later on give rise to cysts, they may be carried upwards towards the floor THE MEDIAN EAl'Ui:. 11 of the mouth away from the skin below the chin by the ingrowth of mesoblast, for the epiderm and endodenn are at first in contact without any intermediate inesoblast. This would account for the existence of such C}*sts in the middle line above the mylohyoid muscle. With regard to those epidermal cysts which have a lateral position near the angle of the jaw and the cornu of the hyoid bone, they may form in a similar way in con- nection with a branchial groove ; there are no true clefts in the human embryo. Another opportunity for the burying of epidermal remnants which may later on form epidermal cysts below the tongue or in the upper part of the neck may occur in connection with the sinus praecervicalis. The first branchial arch, and to a less extent the second arch, grow so much faster than those below that the former overlap the latter, which are, as it were, telescoped and hidden by them. From the middle of the second arch grows down towards the thoracic region a fold compared to a gill-cover or oper- culum, which, therefore, encloses a deep-seated cavity lined by epiderm, and serves for the development of the thymus. The epithelial nest-cells and the occasional cysts found in the thymus are remains of this epiderm, and perhaps other remnants in the neck may give rise to cysts. The median raphe represents the skeleton of the tongue of lower vertebrates. Specimens illustrating this are to be seen in the Physiological Series of the College of Surgeons' Museum. There are Hunter's dissections, including his drawing in the catalogue of the skeleton of the chameleon's tongue. Flower's Lectures at the College of Surgeons, in 1872, describe these specimens, including the tmder- tongue of the lemurs, etc. The typical hyoid bone is formed from the branchial arches by two portions on either side the thyrohyal, or greater cornu, and the keratohyal, or lessor cornu, which join the basihyal, or body of the hyoid. From this projects forwards, in the middle line towards the symphysis of the lower jaw, a rod of bone or cartilage, the glossohyal, or " os entoglossum," or " cartilago entoglossa," the " lingual bone or cartilage " of Hunter. The rod may be firmly fixed or articulate with the body of the 12 DISEASES OF THE TONGUE. hyoid, as in the turtle. In the chameleon the rod of cartilage aids in the extraordinarily rapid and far protrusion of the tongue. It resembles the notocord in having a sheath, noted by Hunter in the case of the chameleon, and, like the notocord also, it tends to disappear in higher vertebrates, leaving the fibrous septum or median raphe. But towards the deepest part of the raphe, in different positions and under different forms, remains are met with all traceable to a common origin. The horse has a strong, bony glossohyal projection, making its hyoid bone look like a spur with the rowel turned forwards. The lemurs show a remarkable under- tongue, partly glandular, with openings of the salivary ducts, and above this the remains of the glossohyal skeleton. In the grand galago there projects a tongue-shaped, rather flat .body of tough fibrous tissue with a median ridge above and below passing into the frsenum. Its edge has finely pointed projections which fit between the incisor teeth and have the appearance of a comb. In the front of the dog's tongue is the " worm " or " style," or " lyssa " or " lytta," " a small worm under the tongue of a dog which, being extracted, is supposed to prevent their becoming mad," which may be coupled with the equally wrong statement that it aids lapping. This glossohyal remnant in the dog is a fusiform body, varying in size from a needle to a crow- quill, composed of fibrous, fatty, and muscular tissue en- closed in a strong sheath. An extreme metamorphosis takes place in some animals, such as the cat, into fat, or the position of the median raphe is occupied by muscular fibres, the azygos lingute, representing doubtless the muscles originally inserted into the periosteum or perichondrium of the median lingual bone or cartilage. The raphe of the human tongue was described by Blandin in 1823 as blade- like, the upper border being hidden in the muscular sub- stance of the tongue without reaching to the free surface, the lower edge being, as it were, free in the interval between the geniohyoglossi. In front it blends insensibly with the mucous membrane, and behind, becoming more marked, joins with the periosteum of the hyoid bone. In some Blandin found evidences of cartilage, and in two aged subjects THE EPITHELIAL SURFACE. 13 bony nodules were met with in the septum. Recently, Xussbaum and Markowski have examined the septum of the tongue in a number of human foetuses and newborn children, and found a structure surrounded by a capsule in the lower part of the septum, which they describe and figure, particularly in the region of the hyoid bone and near the anterior end. Within the capsule was found fat, also in some short rods or islands of hyaline cartilage, especi- ally near the hyoid bone. They found the septum at an early age composed ot much looser connective tissue than that which obtains in the adult, with much fat and numerous blood-vessels. Occasionally fatty and cartilaginous masses were found in the adult septum. Such remnants may quite possibly be the source of tumours. 5. The Epithelial Surface. The stratified epithelium which covers the tongue has characteristics in common with the skin on the one hand, and \vith mucous membrane on the other. It has many affections similar to those of the skin, and it may be affected concurrently in skin diseases. Thickenings of the corneous layers occur, such as is normal in the skin of the palm and sole. Papillomata and epitheliomata are the characteristic new growths in each case. It is not, however, complete epidermis ; it is not derived from the original epiderm, but by transition from the endoderm, and has none of the appendages of the skin. Like mucous mem- brane, it is normally moist, extremely vascular, and freely connected with lymphatics and lymphatic glands. The epithelial surface of the tongue has some connection with the alimentary canal, by which alterations are produced ; but such changes on the surface of the tongue cannot be held to show that similar changes are going on in the mucous membrane of the alimentary canal. Slight variations from the normal in the papillary surface of the tongue in the direction of hypertrophy or atrophy are not necessarily indicative of disease, but may be spon- taneous varieties, approximating types found in the lower animals. Thus, Flower notes in the anthropoid apes very large soft papillae with pointed apices on each side of the dorsal surface of the base of the tongue in front of the 14 DISEASES OF THE TONUI'K. palatoglossal fold. Such conditions in man, when the site of neuralgic pain, have been termed papillomata. The fili- form papillas may be very long, as in the baboon (Cynocephaliis anubis), where they are almost hair-like, and directed back- wards. On the other hand, by the slight development of the filiform papilhe, the tongue may be abnormally smooth. The fungiform and circumvallate papillae are likewise subject to variations. The fimbriated folds and the irregular tags of mucous membrane found on either side of the fraenum and over the sublingual gland may be compared with the pectinated folds mentioned as covering the front of the imder-tongue of the lemurs. 6. The Lingual Tonsil. There is especially developed in man, at the junction of the mouth and nose with the pharynx, a ring of lymphatic gland tissue, the faucial tonsils on each side, the so-called pharyngeal tonsil on the dorsal aspect, and at the opposite part of the ring, on the base of the tongue, a mass of similar lymphadenoid tissue, the lingual tonsil. The base of the tongue is best seen by the laryngoscopic mirror, without drawing out the tongue forcibly. It is only imperfectly seen when the front of the tongue is depressed. In the dead subject the follicles to be described are less prominent, whitish and imperfectly defined, owing to the absence of vascularisation. From the circumvallate papillte backwards to the glosso- epiglottic fold, and extending to the tonsil on each side, the surface of the base of the tongue is partly smooth, partly raised by vascular prominences. The prominences are mostly spherical, 1 to 5 mm. in diameter, one hemisphere projecting from the surface, with a depression 1 mm. broad at the pole, which is the opening both of the follicle and of the duct of mucous glands. The follicles may be few and discrete, or collected into larger masses, with slit-like orifices. They are said to vary from 34 to 102 in number. The existence of these follicles was mentioned by Wharton and Morgagni, and included by them with the tonsils. The first full de- scription is due to Kolliker. According to Stohr, the lymphatic follicles develop in I.IXGUAL ARTERY. 15 human embryos during the eighth month in the neighbour- hood of the mouth of the ducts of tubular mucous glands. Leucocytes wander out from the veins into the fibrillar connective tissue around the duct just below the epithelial surface, and convert it into retiform tissue. The leucocytes collect in the meshwork, and multiplying, form the follicle surrounding the crypt formed by the mouth, the gland duct. Outside the follicle the connective tissue becomes compressed into a capsule. From this adenoid tissue white cells are continually escaping into the crypt, and so into the mouth. Like the faucial tonsils, the lingual tonsil is subject to wide individual variations : to hypertrophy, follicular inflammation and abscess, tumour formation. When the follicles are prominent they tend to hide the upper border of the epi- glottis as seen in the laryngeal mirror, and the glosso- epiglottic sinus is lost to view, even when the tongue is at the same time drawn out, or a high note sounded. 7. The Arteries and Veins in Connection with the Tongue. (A.) The Arteries. The common carotid artery divides opposite the upper border of the thyroid cartilage, lower in long, thin-necked subjects, and higher in those who are short-necked. The bifurcation is so very easily felt in thin subjects that it might possibly be taken for a gland lying on the artery. The external carotid begins nearer the middle line than the internal, which first has a deeper course behind the external, separated from it by the styloglossus and st}dopharyngeus muscles. The external carotid bends slightly inwards in its course up to the angle of the jaw, and is at first superficial, covered only by skin, platysma, the deep fascia, and scarcely at all by the aponeurotic edge of the sternomastoid. It is here situated in the angle formed by the edge of the sterno- mastoid, and by the posterior belly of the digastric and stylohyoid muscle, and gives origin to the superior thyroid, and then to the lingual. The Lingual Artery. Upon the division of the skin, platysma and deep fascia, and the retraction of the sterno- mastoid backwards, and the posterior belly of the digastric forwards, the artery may be exposed, just behind the tip of the great cornu of the hyoid bone, which forms the guide 16 DISEASES OF THE TOX'H'I-:. to the artery. Its distance of origin above the superior thyroid is on an average 12 mm. Soon after its origin it gives off its hyoid bra'nch, which runs along the bone. The artery may be tied in this position, the chief objection being the nearness to the external carotid, which is the more in favour of secondary hemorrhage, especially when the wound in the neck cannot be kept aseptic owing to its communication with the mouth. The lingual artery is commonly tied in the digastric, alternatively, the hypoglossal or lingual triangle objection has been taken to all three names (Fig. 7). To expose the triangle the head is extended and turned to the opposite side ; then it is necessary to raise the platysma and deep fascia with the veins, to be afterwards mentioned, and to strongly 'hook up the submaxillary salivary and adjacent lymphatic glands. Thus there is exposed the obtuse angle made by the two bellies of the digastric. Within the angle is the hyoglossus muscle, and the hypoglossal nerve appears from underneath the posterior belly of the digastric and stylohyoid muscles, and crosses the hyoglossus, to dis- appear beneath the posterior edge of the mylohyoid muscle. If the fibres of the hyoglossus are divided just below the hypoglossal nerve, the lingual artery will practically always be met with running beneath the hyoglossus muscle, having behind it the muscular wall of the pharynx and, a few millimetres forwards, the geniohyoglossus. The artery runs for a short distance parallel to the hyoid bone and just above it. A ligature applied in this position is usually on the proximal side of the origin of the dorsalis lingute branch. After the artery passes underneath the posterior border of the mylohyoid, its course is within the mouth, where it gives origin to the dorsalis linguae, sublingual and terminal ranine branches. The position of the artery within the mouth varies according to the position of the tongue. Three positions of the tongue are, as regards the artery's course, of interest : (n) when the tongue lies at rest in the mouth, (6) when the tongue is forcibly drawn out of the mouth, (c) when the tip of the tongue is curled upwards. (a) When the tongue lies at rest in the mouth, the lingual artery as viewed from the side takes an arched course from the apex of the great cornu to the tip of the THE LINGl'AL ARTERY. 17 tongue; the more the tongue is retracted, the higher the arch. From about the highest part of the arch the dorsalis lingua? branch is given oflf. When a finger is passed down to the epiglottis, and the tip of the great cornu felt through the pharyngeal wall, then the artery is arching forwards between the finger and the angle of the lower jaw, and by pressing the finger outwards the artery is compressed. Thus, haemorrhage from the cut end of the artery may be temporarily controlled. L't. Fig. ,). DIAGRAM OF A TBANSVEBSE SECTION OF THE TONGUE AT THE AlTTEEIOE EDGE OF THE MASSETERS. L. J. Lower jaw. L. A. Lingual artery. F. A. Facial artery. D. L. A. Dorsalis linguae artery. M. Masseter. Stp. Styloglossus. Ghg. Geniohyoglossus. Gh. Geniohyoid. MyL Mylohyoid. Dg. Digastric, it. Platysma. 8m. G. Submaxillary gland. (6) When the tongue is forcibly drawn out of the mouth the hyoid bone is pulled upwards, and the course of the artery becomes approximately a straight line, from the apex of the great cornu to the tip of the tongue, the two arteries converging to this point. The artery is found immediately beneath the denser muscular substance, separated from the middle line by the geniohyoglossus muscle (Fig. 5). It is here surrounded by a loose connective tissue, which allows of the cut end of the artery being drawn out a little. Running close to the artery on the outer side is the lingual nerve. (c) When the tip of the tongue is curled or held up, there appear spread out on either side of the middle line the ranine veins and their venules. Immediately beneath the vein exposed, therefore, by removing the mucous membrane and the vein runs the ranine artery, accompanied on the outer side by the lingual nerve (Fig. 6). The nearer the arteries are to the tip, the more they approach one another, c 18 -DISEASES OF THE TONGUE. Moreover, with the tip of the tongue drawn up, the sublingual gland beneath the mucous membrane is also lifted. In the superficial part of the gland thus rendered prominent runs the sublingual branch, which may thus be easily included in any wound, surgical or accidental, involving the fnenum and adjacent mucous membrane of the floor. Fig. 6. DlAGHAM OF THE UNDER SURFACE OF THE TlP OF THE TONGTTE WHEN DRAWN Our AND HELD UP. V. Ranine vein. A. Ranine artery. X. Lingual nerve. F. Fr*num. S. Salivary papilla. Abnormalities of the Lingual Artery. The lingual artery is one of the most constant of all the arteries, both as regards its origin and its course. It may arise a little lower than usual in common with the superior thyroid, but as it then ascends into the digastric triangle, there is no change in the operation for its ligature. It may arise higher than usual in common with the facial artery. In this case the artery has to descend to pass under the mylohyoid, and is therefore found in the digastric triangle higher than usual, at the level or above the level of the hypoglossal nerve. (Gruber.-) Occasional instances of other anomalies have been met with in the dissecting room, but although surgeons may have missed the artery at operations, there is no convincing LINGUAL ARTERY ABNORMALITIES. 19 account of the artery having been really absent from the digastric triangle. The anomalies found may be explained by the enlargement of some usually fine twig to take the place of the undeveloped main vessel. In Shepherd's case this was the normal hyoid branch. The artery arose, in common with the superior thyroid opposite the upper border of the thyroid cartilage, passed upwards on the thyrohyoid muscle, crossed the hyoid bone anterior to the lesser cornu, then upwards beneath the anterior belly of the digastric muscle, arid pierced the hyoglossus muscle. A more common anomaly is the enlargement of the twig which runs along the hypoglossal nerve, superficial to the hyoglossus. This was found by Zuckerkandl and Funke, and Croly has noticed it six times. The artery arises from the external carotid about its usual level, and runs over the hyoglossus parallel to and a little below the hypoglossal nerve, until, at its inner edge beneath the mylohyoid, it reaches the outer surface of the geniohyoglossus. But in Hyrtl's case the artery passed over the hyoglossus under the anterior belly of the digastric on the mylohyoid until it reached the chin, where it pierced this muscle and passed backwards between the geniohyoid and the hyoglossus externally and the geniohyoglossus internally. Here there was the enlarge- ment of a submental twig. Louth pere is quoted as having found a very small lingual ending in the depth of the tongue, a sublingual ranine branch being supplied by the internal maxillary artery. The sublingual branch may be substituted by the submental branch of the facial. The External Maxillary or Facial Artery. The facial artery arises from the external carotid close above or even in common with the lingual artery, and takes a tortuous course before it becomes superficial upon the lower jaw at the anterior border of the masseter muscle. Its course is from the level of the great cornu of the hyoid bone or just above, at first upwards underneath the posterior belly of the digastric and the stylohyoid muscle, then underneath the overhanging submaxillary gland. The artery does not actually penetrate the capsule of the gland, but at the hinder part of the gland, where it and the beginnings of Wharton's duct hook round the mylohyoid, the capsule encloses the artery in a sheath. 20 DISEASES OF THE TONGUE. Here the artery gives off its submental branch, which runs along under the lower border of the jaw, enclosed by the anterior part of the gland. The facial artery is seen when the deep fascia has been divided and the submaxillary gland hooked up over the ratnus of the jaw. The artery is thus stretched out, and extends from the posterior belly of the digastric and stylohyoid across to the gland, behind the border of the mylohyoid and above the course of the hypo- glossal nerve. (B.) The Veins from the Tongue. The veins passing from the tongue and floor of the mouth across the submaxillary region run between the layers of fascia or beneath the deep fascia, and have irregular communications, as can be found on anatomical examination. But the general experience of surgeons leads to the conclusion that greater irregularities prevail than even anatomical de- scriptions give. This is no doubt largely due to the dilatation of small veins and the formation of communicating venous plexuses, as a result of disease. The veins may be divided into three groups, according as they mainly join the internal jugular, external jugular, and anterior jugular respectively. The facial and lingual veins joining the internal jugular about the level of the hyoid bone are the chief ones. The anterior facial vein, receiving blood from the face and chin, sometimes runs in front of the submaxillary gland, superficially between the layers of fascia, sometimes is united to the gland and lies beneath the deep fascia. It receives veins from the submaxillary gland, also submental veins across the digastric triangle. The lingual vein is formed by the sublingual, which runs across the digastric triangle just below the hypoglossal nerve. Venae comites come from the tongue and run along the course of the artery backwards, receiving the dorsalis linguae under- neath the hyoglossus, and then, joining with the more superficial sublingual, compose the lingual vein which enters the internal jugular separately or in conjunction with the facial vein. The superior thyroid vein joins the lingual or facial, or both, before entering the internal jugular, and is therefore met with in the larger submaxillary operations. Submental veins tend towards the anterior jugular, but LYMPHATIC GLANDS. 21 also communicate with the facial or internal jugular. Veins from the base of the tongue and submaxillary glands, also communications with the anterior facial, cross the sterno- mastoid to the external jugular. s. The Lymphatics and Lymphatic Glands. The most prominent question in connection with diseases of the tongue viz. the greater prolongation of life after operations for cancer concerns the lymphatics and lymphatic glands, and how far the knife of the surgeon should go in the removal of glands not obviously diseased. At first sight the question looks an almost hopeless one when it is found that fine injections into any point of the tongue can be made to penetrate into the lymphatic glands through the lymphatics in every direction. But, of course, this free intercommunication must be studied in connection with the peculiarities which cancer exhibits in slipping through the lymphatics like emboli to lodge in glands, and many more exact observations are required to connect the starting points of cancer with the glands first infected. At any rate, both anatomical and clinical observations emphasize the great importance of the fact that the main lymph channels from the tongue have their junction in the chain of glands lying on the internal jugular vein, about the level of the hyoid bone and the bifurcation of the carotid. A full description of the lymphatics and lymphatic glands was given by Sappey, to whose work, until recently, sufficient attention had not been given by surgeons. It has been confirmed by Kuttner. The lymphatics of the epithelium of the dorsal surface of the tongue and floor of the mouth can be injected by plunging in a fine needle beneath the epithe- lium at any point, except as regards the base of the tongue behind the circumvallate papillae, from which the lymphatics pass to the tonsillar region, and the communication with the rest of the tongue is not so free. The fine capillaries are collected into lymphatics with frequent communications, which, after running in the submucous tissue, dip down deeper towards the lymphatic glands. Lymphatics from the muscular substance take a similar course : some of the main lymphatics run across the surface of the hyoglossus, others follow the course of the lingual artery. 22 DISEASES OF THE TONGUE. Submaxillary Lymphatic Glands (Fig. 7). There are several glands in the loose connective tissue of the digastric triangle between the lower jaw and the mylohyoid muscle. They are met with as far forwards as the anterior belly of the digastric and backwards up to the parotid. They may lie Sm. G. L. J. v Qi \ / 'jit L. J. C. A. Fig. 7. DIAGRAM OF THE LYMPHATIC GLANDS AND OTHEK STRUCTURES BELOW THE JAW AND IX THE XECK. Lymphatic glands: (1) (1) Submental. (2) (2) Subinaxillary. (3) (4) Upper deep cervical glands, called also sternomastoid or carotid or jugular glands ; the highest gland, marked (4), is especially infected early. C. A. Common carotid artery. T. A. Superior thyroid. L. A. Lingual, passing under hyoglossus and mylohyoid muscles. Fa. Facial. By. X. Hypoglossal nerve. I.V. Internal jugular vein joined by L.V. Lingual vein, also at the same place by the facial vein above and the superior thyroid vein below. L. J. Lower jaw. Sm. G. Submaxillary gland. Stm. Anterior border of the stern omastoid. Dg. Digastric muscle. Sth. Stylohyoid. Sth. Sternohyoid. Oh. Omohyoid. Thh. Tliyrohyoid. H. Hyoid bone. adherent to the salivary gland capsule or between its fold. As mentioned before, lymphatic gland substance is met with inside the capsule and between the lobules. These glands receive lymphatics from the whole of the margin of the tongue as far as the anterior pillar of the fauces, from the median portion of the front half of the tongue, from the under-surface of the tip and from the floor of the mouth. Lingual Glands. Small glands are met with between the geniohyoglossi, also on the outer surfaces of the muscles. They are on the course of the lymphatics, but are not end HYPOOL088AL NERVE.: 23 stations, and the epitheliomatous infection is not arrested in them. Submental Gland*. One or two glands lie in the sub- mental triangle, receiving lymph from the region of the fnemim, thence efferent channels lead to the submaxillary glands. Parotid Lymphatic Glands. The lower end of the parotid salivary gland, where it is overlapped by the sub- maxillary, contains lymphadenoid masses which receive lymphatics, especially from the soft palate. Upper deep Cervical Glands (Glandidce cervicales pro- fundcv super lores). A chain of glands lies generally on the internal jugular vein (Fig. 7), overlapped by the anterior edge of the sternomastoid muscle, less often directly over the in- ternal or external carotid, but almost always over the common carotid near its bifurcation. They extend from the level of the bifurcation of the carotid upAvards, and may do so nearly up to the skull. These glands are the chief ones of the tongue. They are end stations on the course of the lym- phatics, whore epitheliomatous infection becomes arrested. Lymphatics come to these glands from the whole tongue and floor of the mouth, the anterior and posterior pillar of the fauces, the tonsil, the dorsal surface of the soft palate, as well as from the pharynx. Lower deep Cervical or Supraclavicular Glands (Glan- didce. cervicales profwnddB inferiores). The highest of these glands lies at the point where the internal jugular vein is crossed by the omohyoid, and they extend as a chain down- wards behind the clavicle ; from them the afferent lymphatics join the internal jugular and subclavian veins independently of the thoracic duct. They receive afferent lymphatics from the upper cervical glands. There are also lymphatics which come direct from the tongue to these glands, chiefly from the region of the frcenum and adjacent part of the floor of the mouth as far back as the middle of the sublingual gland, and sometimes from the dorsum of the tongue to the same extent. 9. Nerves of the Tongue. H y i >o**! Xcri-f. -The muscles of the tongue are connected with the opposite motor area of the brain at the 24 DISEASES OF THE TONGUE. lower end of the fissure of Rolando. The connection is through the corona radiata, internal capsule and crusta, and then the fibres cross to the opposite hypoglossal nucleus, crossing below the level at which the fibres going to the facial nucleus cross, so that paralysis of the tongue may occur on the opposite side to that of the face. The different cases of paralysis of the hypoglossal nerve may be grouped according as the part involved is the nucleus, the root passing through the condylar foramen, the nerve running close to the atlas vertebra, then emerging deep in the neck and closely connected with the vagus ; next crossing the carotid artery, the nerve appears in the digastric triangle, dividing there to go to the several muscles. Vasomotor efferent fibres pass from the cervical sym- pathetic to the smaller branches of the lingual artery in the muscles, i.e. the arterioles, by means of which the constriction and dilatation of these vessels can vary the blood flow. Afferent Nerves of Common Sensation and of Taste. The afferent nerves of the tongue are complex. The lingual nerve is the nerve of common sensation and of taste to the anterior two-thirds of the tongue. The fibres of common sensation are connected with the fifth nerve through the Gasserian ganglion. It is not certain whether the taste fibres have a similar course, or whether they reach the lingual nerve through the chorda tympani, or come from the glosso- pharyngeal through Jacobson's nerve, the tympanic plexus, the vidian nerve, and otic ganglion. Pain felt in the ear in cases of disease of the tongue, and conversely, pain in the tongue from irritation of the ear, e.g. by wax in the auditory meatus, is explained as due to the connection of the lingual and auriculo-temporal nerves, both belonging to the third division of the fifth. The chorda tympani nerve is apparently a nerve of taste in man, for when the nerve is touched as it crosses the ear sensations of taste are experienced, and the sense of taste is blunted in cases of facial paralysis when the nerve is involved in the acquajductus fallopii. It may, by joining the lingual, be the means of adding taste fibres to that nerve. The chorda tympani may arise by the pars intermedia of GLOSSOPHARYNGEAL NERVE. 25 \Vrisberg from the upper end of the glossopharyngeal nucleus, and so all the taste fibres of the tongue have their source in one centre. The glossopharyngeal nerve is the nerve of common sensation and of taste to the posterior third of the tongue. The pain felt in the ear in consequence of disease of the base of the tongue may be due to its being referred to Jacobson's nerve in the tympanum. Supposing the taste fibres to run in the glossopharyngeal, they would have their origin in connection with the root of that nerve. It has been supposed, however, that the fifth nerve is the nerve of taste, and that the glossopharyngeal obtains taste fibres from the fifth through the vidian or petrosal nerves, the tympanic plexus, and Jacobson's nerve. The superior laryngeal nerve sends fibres to the base of the tongue and epiglottis, hence the ease with which disease in this position may give rise to reflex cough, hic- cough, or vomiting. It may also explain the ease with which spasm of the glottis and pharynx may be caused by sudden depression of the base of the tongue. On the other hand, the excitation of the respiratory movements when the tongue is forcibly drawn upon, may be due to stimula- tion through this nerve of the respiratory centre. (Laborde.) Obstinate hiccough, too, has been relieved by traction on the tongue. (Lepine.) 26 CHAPTER II. THE CONGENITAL DEFECTS OF THE TONGUE. Absence (so-called) of the Tongue Bifid or Split Tongue Congenital Ankylo- glossia, Adherent Tongue, or Tongue-tie : () Exceptional Occurrence, Bad Effects of Unnecessary Division of the Fraeuum ; (/;) followed by Haemorrhage, Tongue Swallowing and Asphyxia, Macroglossia ; (c) Division of the Fraenum ; (d) Treatment of Accidents following Improper Division Excessive Mobility : (a) Tongue Swallowing, (b) Tongue Sinking Back, (<) Extreme Length of the Tongue Congeuitally Enlarged Papillae. MALFORMATIONS of the tongue are due to an arrest at some stage in the course of the development of the tongue, in- cluding the persistence of union with the palate, owing to the incomplete opening made between the primitive mouth and the gullet. Defects of any kind are rare, the most frequent being spoken of clinically as abnormal fixation of the tip of the tongue, ankyloglossia, or tongue-tie. The still rarer malformations have been named " absence of the tongue," or "fusion of the tongue with the floor of the mouth." None of these names is connected with the origin of the condition. In reference to the process of development, briefly mentioned in the foregoing chapter, it is the " tuber- culum impar " which is the site of all the congenital defects. If it falls short by a little of growing forwards to produce the projecting tip, " tongue-tie " is seen ; if it is entirely arrested in its growth, we have the " absence of the tongue," i.e. of the anterior projecting part. No case has been described of the absence of the base of the tongue as formed behind the lingual V. It was evidently present in Jussieu's case, for the girl could speak plainly and distinctly except for a few letters, and the same applies to other cases. In the relative absence of the " tuberculum irnpar," the forked anterior part of the "tubercle of the base" may grow forwards and produce the " bifid tongue." Some of these ARRESTED DEVELOPMENT. 27 defects have occurred with malformations of the upper and lower jaws, especially in monsters. 1. Absence (so-called) of the Tongue, i.e. arrested De- velopment of the Tuberculum Impar of His. This is a condition so rare that all works on diseases of the tongue quote the case related by Jussieu in 1718. This really appears to be the first case on record, for the best writers on congenital defects neither relate other cases nor give references to works in which they may be found. One may believe that Weber had seen a case, since he says that the place of the absent tongue is occupied by two movable nodules, whereas the patient described by Jussieu had only one nodule. However, it cannot be supposed that Weber could have really seen so rare a condition and not have carefully recorded it. At the age of fifteen years the girl described by Jussieu had, in place of tongue, a small elevation in the middle of the floor of the mouth, about three or four lines in height. It was to a certain extent movable, the muscles at the base of the tongue being fairly developed, and was evidently very useful in speaking and in swallowing. Speech was very little affected by the absence of the tongue ; it was, indeed, so clear that no one would have suspected that so serious a defect existed. There was a little difficulty with the letters (in French) c, f, g, 1, n, r, s, t, x, y, z. This circumstance, which excited great surprise and doubt in the beginning of the eighteenth century, would not be considered so remark- able now. That speech may be retained when the entire tongue has been removed has been proved so often of late years that the fact has ceased to appear wonderful. Mastica- tion and the swallowing of solid food were the only acts which were really difficult to this patient : mastication because she was prevented by the absence of the tongue from collecting the food from about the teeth and between the teeth and cheeks : deglutition of solids because she could not carry the food back to the pharynx as usual with the tongue. She was therefore obliged occasionally to supply the defect by using her fingers to gather in the food and thrust it to the back of her mouth. She could spit by aid of the mylohyoid. She could not suck as an infant 28 DISEASES OF THE TONGI'K. except when the mother compressed the breast at the same time. The nerves which supply the tongue with taste and touch appear to have been perfect so far as the maintenance of these functions was concerned. It is probable that the lingual branch of the fifth and the anterior portion of the glossopharyngeal passed into the mucous membrane of the floor of the mouth, and terminated there in normal filaments in or immediately beneath the epithelium. We have sometimes been inclined to wonder whether this was a true case of congenital absence of the tongue, or whether it was not rather a case of the kind described by Aurran and Roland de Belebat of loss of the tongue as the result of some destructive disease. Several cases are described in old medical literature of loss of the tongue from small-pox, an accident apparently much more frequent in past times, when small-pox was more destructive than it has been in the present century. The appearances recorded in some of these cases do not differ widety from those recorded by Jussieu. But Jussieu was acquainted with Roland de Belebat's case, and specifically mentions that the girl was born so. Moreover, the situation of the small elevation in the floor of the mouth of the girl accords with the theory of arrest of development ; for the first appearance of the tongue in the foetus is, as first described by Kolliker, a projection or swelling on the middle of the inner aspect of the first branchial arch. This projection unites at a later period of foetal life with a second projection proceeding from the second arch. The development of the tongue, therefore, in the case related by Jussieu points to an absolute failure of the projection from the inferior maxillary arch, and to a partial development of that which proceeded from the second pharyngeal arch. Duplouy, under the title " Complete Fusion of the Tongue with the Floor of the Mouth," gives a somewhat similar case. The tongue of a child aged two and a half months did not project at all from the floor of the mouth, and no muscular substance was to be felt with the finger, whilst the hinder part of the tongue was normal. The child was in danger of dying of starvation, as it could not suck well. After a long discussion in the French Surgical Society, the general BIFID TONGUE. 29 opinion was against any operation, and recommendations were made as to feeding by spoon, by extra long teat, or by oesophagus tubes. 2. Bifid or Split Tongue. Children are occasionally born with a longitudinal fissure, which divides the fore part of the tongue into two equal parts, and which extends, in some instances, a considerable distance back towards the root. The condition is peculiar, but, as has frequently been pointed out, is analogous to the natural condition of the tongue in certain of the lower animals. The seal among mammals has a bifid tongue; the raven among birds; but the division of the fore part of the tongue into two reaches its height in reptiles, among which many of the snakes, with their extremely forked tongues, may be taken as examples. A bind tongue does not appear to affect the functions of the organ in any serious degree : therefore, no operation need be undertaken to unite the two halves. But an operation may be asked for in consequence of the ugliness of the deformity, and if it be desired, there is no reason why it should not be performed, provided the patient is strong and healthy. The opposed surfaces of the cleft must bo pared and brought together with sutures. There is not any serious bleeding, and the wound will probably heal by first intention. The manner in which the splitting of the tongue is to be accounted for by an arrest of the " tuberculum impar " and the growing forward of the forked " tubercle of the base " has been already referred to. A bifid or cleft tongue has been seen with a cleft lower lip, also with an ill-developed lower jaw, with or without harelip and cleft palate. The upper and lower jaws may be, however, quite well formed. Ahlfield has also observed deep clefts of the face occurring with bifid tongues. A bifid or split tongue must, of course, be distinguished from a so-called "double tongue," produced by a ranula under the tongue or by enlargement of the sublingual salivary glands. Ahlfeld suggested that the simpler or slighter conditions mere notches at the tip of the tongue were connected with a short fnenum, and this is probably the case. Septours described an anencephalic monster in which, besides 30 DISEASE* Or THE TONGUE. an extensive harelip and cleft palate, the tongue was divided into three portions. The two lower rested on the floor of the mouth, which they entirely filled, one on either side. Each had a sort of frsenum, beyond which they projected a little. A third portion was fixed in front to the nasal septum between the cleft of the palate, and projected between the lips. On its under-surface were papillae and fine down hairs. Here we have the forked tubercle of the base forming the two masses on the floor, and the tuberculum impar adherent to the upper jaw owing to the incomplete separation of the primitive septum between the mouth and pharynx. In Griffiths' case of a male infant only the posterior part of the tongue was developed, so that it looked like the stump of a tongue after amputation. The stump was closely applied to a cleft in the hard palate ; the soft palate was adherent to the naso-pharynx, so that there Avas no opening of the pos- terior nares. The cheeks were partly adherent to the gums, and the gums to one another. The child cried and sucked the finger, but could not take the breast. 3. Congenital Ankyloglossia, Adherent Tongue, or Tongue-tie. (a) Children are born with the tip of the tongue adherent to the floor of the mouth owing to a very short fnenum and folds of mucous membrane on each side of the frgenum. This is due to the projecting portion of the tongue being in- completely developed from the tuberculum impar. In many of the slighter cases the development has merely lagged behind, and will be completed as the child grows after birth. And this backward state of the tip at birth is doubtless the source of the superstitions which have surrounded the subject of tongue-tie. The real persisting cases are excessively rare ; most surgeons have never seen a congenital case. This question of excessive rarity of tongue-tie has to be emphasized on account of the harm done by the unnecessary division of the framum, with the results to be recorded : the septic ulcer, with its inevitable puckered scar, leaving the tongue more fixed than before ; the fatal haemorrhages ; the falling back of the tongue, causing " tongue-swallowing " and suffocation, and later, inacroglossia or the impairment of the future singing voice. The superstition is a hoary one. Celsus describes it DIVISION OF THE F1LVNUM. 31 and warns against injury of the ranine veins. It is one of the tc\\ errors made by Ambrose Pare, who advises, after division of the frsenura, that the finger should be inserted under the tongue to lift it up, a procedure which has been the death of many infants. Fabrizio d'Acquapendente was the first to attack this evil custom, saying that the midwives of his day kept a finger-nail sharp for the purpose of tearing through the f'r;riium and stripping up the tongue of all new-born children. It has been disclosed concerning fatal cases of haemorrhage or tongue-swallowing that the midwife has been accustomed in a great number of cases to snip through the fni'iium with a pair of scissors and strip up the tongue. It cannot be denied also that many practitioners have too often done the same unnecessarily and carelessly, to the injury of the child. The doctor is pressed by the mother to operate, and as the operation seems very trivial and is easily per- formed, if there is the least doubt whether the fra?num should be divided, he yields to the pressure put upon him. (6) Fatal Haemorrhage after Division of the Frwnum. The following case is described by Burton. A non-certificated midwife, who said that she had frequently performed the operation, using always sharp-pointed scissors, divided the frsenum of a male child one hour after birth, making a cut between half an inch and three-quarters of an inch long, com- mencing to the right of the middle line and extending to the left. Bleeding was noticed a few hours afterwards, the blood coming out of the child's mouth. The next day bleeding con- tinued, and dark blood was passed by the bowel. Two days after birth the child was seen by Dr. Burton. Arterial bleeding was going on, and two ligatures were applied. The child had become very anaemic ; it passed more blood by the bowel, and died rather suddenly on the third day. Post mortem all the organs were found healthy, but very anaemic. In the stomach and intestines, throughout almost their whole length, was much semi-fluid blood. A ligature was seen occluding both the left ranine artery and vein. The jury at the inquest found ' : Death by misadventure." Reboul described a similar case in which a doctor had divided the framum a few hours after birth. There was continued oozing in spite of all treatment by pressure, 32 DISEASES OF THE TONGUE. cautery, etc. The ulcer got larger, there was increasing pallor, melaena, and finally death on the sixth day. Many more such cases have been noted. The division of the fnenum is a common cause of asphyxia and tongue-swallowing. Two of the three cases described by Petit in 1742 died with all the symptoms of suffocation within a few hours after the frsenuin had been divided ; and other similar cases have happened. Macroglossia has followed as a direct result of division of the frsenum. In Sediilot's case the macroglossia was seen in a boy aged nine, in whom the frsenum had been divided five years before to facilitate speech. In Db'llinger's case of a man aged twenty-one, the macroglossia dated from the division of the frcenum at the age of two. (c) However rare, it cannot be doubted that there are cases of tongue-tie needing division. Joachim describes cases, and quotes those of Potter, where a number of children of the same family could not suck until the fnenum was divided. It may be said, nevertheless, that such cases could have been brought up by hand. About other cases there is still more doubt. Dieffeiibach, in 1841, described division as a remedy for stuttering. His first case soon relapsed, and no success was obtained by surgeons who followed. Makuen, in the United States, has recently published three cases : one, a youth aged nineteen, who had never been able to utter four consecutive syllables intelligibly in his life. A year after the division of the fnenum, includ- ing the attachments of the geniohyoglossi, he could declaim a scene from Shakespeare better than the average. The second case was that of a boy who could not protrude the tongue beyond the teeth. After division of the frsenum he could protrude it and talk plainly. A third case occurred in a woman aged twenty-five. There must be some nervous element in such cases. Broca describes a case of superior ankyloglossia where the tongue adhered to the palate, and a separation had to be made before the child could take its food. Division of the Frcenum. It follows, therefore, from the above, that the frsenurn ought to be divided in an infant only after due deliberation. It ought not to be considered a TONGUE SWALLOWING. 33 trivial operation, and no midwife nor other unqualified person should be allowed either to cut the fraenum with scissors or to tear it through with the finger-nail. The cutting of the frsenum is performed by placing the fore and second finger of the left hand beneath the front of the tongue, one on each side of the fraenuin, so as to raise up the tip and tighten the band to be divided. The grooved sound or director with its flat split handle was invented by Petit, and is perpetuated by instrument makers. But it requires a longish fraenum to enter the slit, i.e. a kind of case which does not require the division. Petit's idea was to cut underneath when the frasnurn was in the slit, the ranine artery and vein being thus protected from injury by the flat surface. Having raised up the tip so as to make the band tense, a minute snip should be made through the mucous membrane, close to the inner surface of the lower jaw. The insertions of the geniohyoglossi should never be divided, nor should the tongue be stripped up by the finger. The old plan was to put the child to the breast immediately, the sucking being supposed to arrest the haemorrhage by pressure. (d) Treatment of the Accidents following excessive Divi- sion of the Frcenum. A surgeon may be called upon to treat as an urgent case an infant with haemorrhage and threatened tongue-swallowing, owing to wrongful division of the fraanum. He should first put a silk ligature through the tip of the tongue, and draw it forwards. If there appears to be little but oozing, he may gently wipe out the mouth and clean the wound, dust on a little iodoforin powder, and insert a little strip of gauze. The drawing forwards of the tongue will then press the gauze against the lower jaw. The ligature through the tongue, as well as the end of the strip of gauze, should be fixed to a lightly applied ordinary chin-bandage. If the haemorrhage is more severe, it may be necessary, after obtaining assistance, to give a little chloroform, open and clear out the mouth, and then ligature the bleeding point, using the greatest care or the friable tissue will tear further. The cautery should not be used, for secondary haemorrhage may occur when the eschars separate. 4. Excessive Mobility, Tongue- swallowing. (a) As there are cases in which children are born with D 34 DISEASES OF THE TONGUE. too short or too tight a frsenum, so there appear to bo cases in which children are born with too long a frsenum. At first sight, it does not seem probable that such a condition as too long a frsenum would attract the attention either of the doctor or of the relatives of the child ; but the records of some of the cases show that this is a much more serious defect than the other. Too short a frsenum has never, so far as we are aware, been directly the cause of the death of a child, but several children are reported to have died because the frsenuin was too long. Attention was first drawn to the subject by Petit in 1742, in a memoir to the Academic Royale des Sciences, in which he related three cases of children in whom the fraenum Avas so long that it failed to exercise its due influence in fixing the fore part of the tongue, so that two of them, drawing the tongue back into the pharynx in the act of swallowing, died suifocated. The third child was reared with difficulty by keeping a continual watch over it. Since 1742 several papers have been published on the subject, some of them containing cases in point, but the defect or the danger of death from the defect does not appear to be at all common ; or, if it is common, it must be very generally overlooked, and the deaths must be attributed to some other cause. Even in several of the cases in which children have died from swallowing the tongue, the primary defect was not Congenital : the frsenum was probably natural at birth, but it was -divided within a very short time after birth, and its natural bearing on the tongue was destroyed. Two of the three cases related by Petit were cases of this kind, in which the operation was performed a few hours after the children were born. The evidence is founded on post-mortem examination of several patients, and the description of the manner of death and' of the appearances observed after death is very clear, and points decidedly to suffocation by the tongue. Petit's two tiny patients died with all the symptoms of suffocation within a few hours after the frsenum had been divided, and Petit made the examination by splitting open the cheek in such a manner as not to disturb the relation of the parts within the mouth. He found the throat com- SINKING BACK OF THE TONGUE. 35 pletely filled by the tongue, the tip of which was turned back over the dorsuin, and fixed, like a wedge, in the upper part of the gullet. The obstruction to the larynx was so complete that no air could possibly have passed into the lungs. (6) Sinking Back of the Tongue. A case recorded by Fairbairn differed from those by Petit. The child had a cleft palate, and whenever more than a very small quantity of liquid was dropped into its mouth, it was attacked by cough and threatened with suffocation. When it was two days old it died, apparently from suffocation. At the autopsy the tongue was found to be short and thick, with a very defective foenurn. The tip was not retroverted, but the whole tongue lay so far back that only the tip was visible at the back of the mouth. The dorsum was applied against the back wall of the pharynx, and the base pressed down on the epiglottis and arytenoid cartilages in such a manner that the entrance to the larynx was completely blocked. Fairbairn said that he had had another somewhat similar case, but the infant had been reared. Hennig mentions two cases in which children between three and four months old died suffocated during a paroxysm of whooping-cough, apparently from sucking the tongue into the pharynx in the long act of inspiration which occurs between the fits of coughing, but neither of these cases had been seen by himself. They occurred in the practice of a fellow - practitioner, by whom they were related to Hennig. Hennig refers to the drawing back of the tongue in sleep and in catarrh, and speaks of it as if it were not uncommon, and a source of danger to children fed for the first time with a spoon. His paper is worthy to be read, but he appears to attribute too great importance to the possibility of suffocation from drawing or sinking back of the tongue. Sinking back of the tongue is known to occur after opera- tions in which the attachment of the geniohyoglossi muscles has been separated from the lower jaw. The accident is now so far recognised that precautions are taken to prevent it in those cases in which the symphysis has been removed, or in which a large operation, implicating the anterior attach- 36 DISEASES OF THE TONGUE. ments of the tongue, has been practised. With these con- ditions in mind, it is not very difficult to imagine such an accident as that described by Fairbairn. Ingals has related a case of a very dyspeptic and hysterical woman, twenty-eight years old, who suffered on several occasions from attacks of suffocation, and who said that her tongue seemed much farther back in her mouth than she could voluntarily put it, and that the tip was pressed up against the palate, and seemed curled over on the dorsum. But the inverted posi- tion of the fore part of the tongue was not proved by the doctor, and was only a supposition on the part of the patient, whose evidence can hardly be regarded as very valuable. The sudden depression of the tongue of a child in order to examine its fauces has set up severe respiratory spasm lasting an hour or two, and one fatal case of convulsions followed the sudden depression of the tongue. It is a wise rule to make a child say " a," if possible, when depressing the tongue. (Vergel.) Tongue-sucking is a vice to which mentally deficient and idiot children may become addicted. Lindner's paper has illustrations of this and finger and lip sucking. It may produce caries of the teeth and even dislocation of the jaw. With regard to treatment, if a child is suddenly suffocated there is no time to procure medical assistance. But if a child is threatened with suffocation, and escapes on the first occa- sion, and the cause of the threatened death is discovered to lie in an ability to " swallow " the tongue, it is possible that careful management may succeed in averting the cata- strophe. Both Petit and Fairbairn mention cases in which children were exposed to the chance of death from this accident, but the patients were successfully reared. The attendant hi each case was very cautious, in feeding the child, not to give it too large a quantity at any one time ; and when the access of suffocation was observed, it was arrested by putting the finger into the child's mouth and, presumably, correcting the position of the tongue. When- ever the child whose case is recorded by Petit was seemingly inclined to suck back its tongue, it was supplied with a substitute in the form of the teat or the finger. It may EXTREME LENGTH OF TONGUE. 37 probably be taken as a rule in the treatment of these rare cases that the children should be fed with the breast either of the mother or a wet-nurse, if it is possible ; and, failing this, with an artificial teat in preference to a spoon. In such a case as that related by Fairbairn it would not be possible, in all probability, to carry out this recommenda- tion, for the infant had a cleft of the palate. If the child is attacked by suffocation, either during or between the in- tervals of feeding, the attendant should at once pass a finger into the mouth, between the tongue and palate, and, passing it far back, draw the tongue forward. There is no difficulty in doing this if the finger is passed sufficiently far back. The woman whose case is described by Ingals cured herself in this manner ; but too great weight must not be attached to this case, on account of the element of hysteria which prevailed so largely, and also of the great doubt which must be felt of the exact conditions which obtained. (c) Extreme length of the tongue must be regarded rather as a congenital peculiarity than as a defect. Instances of this condition are the two quoted by Clarke from Fournier. One of the persons was a lady whose tongue was so long that when it was protruded it hung over the teeth in folds ; the other was a girl who could touch her chest with the tip of her protruded tongue. Other persons have been able to touch the point of the chin, the tongue being protruded as freely as that of a dog. The extreme length of the tongue in these persons does not appear to have been attended with any great inconvenience, and they are only mentioned that nothing which is of interest in connection with this subject may be omitted. In relation to this matter, it may be mentioned that, both in ancient and in modern times, defect of speech, particularly an imperfect and slovenly articulation, has been attributed to too great length and size of the tongue. This impression may be correct. But, on the other hand, it will be observed in the section on hypertrophy of the tongue that even a considerable enlargement, so great that the organ protrudes habitually from the mouth, does not very greatly impair the speech. 38 DISEASES OF THE TONGUE. 5. Congenitally-enlarged Papillae. Many of the warts and warty growths of the tongue undoubtedly owe their origin to hypertrophy of one or more of the natural papillre of the tongue, but we have met with one instance in which there was hypertrophy of certain of the papilloe all over the papillary aspect of the dorsum, with the production of tuft-like growths which did not resemble the usual warty growths, and which could not well be classed among the true tumours of the tongue. They are conditions which may be compared with that existing in some animals. Others may be early stages of partial macroglossia. 39 CHAPTER III. ACCIDENTS TO THE TONGUE AND ACQUIRED DEFORMITIES. Bums and Scalds Stings and Snakebites Wounds of the Tongue : (ff) Bites ; (i) Hemorrhage from Wounds ; (c~) Bullet Wounds ; (d) Wounds of the Tongue involving the Large Vessels of the Xeck Foreign Bodies in the Tongue Acquired Aiikyloglossia, or Tongue-tie Results of Removal of Part of the Tongue Acquired Excessive Mobility. 1. Burns and Scalds. Trivial burns of the tongue are of very frequent occur- rence, both in children and in adults, from taking food which is too hot into the mouth. The burnt spot is painful and very tender for a while, and is redder and smoother than the rest of the surface of the tongue, or, perhaps, it is actually excoriated. The material is seldom, so hot or retained so long within the mouth as to produce sloughing of the cutis vera of the mucous membrane or even to raise up the cuticle, but the superficial portions of the papilla) are destroyed, and falling, leave a smooth area. In the course of a few hours, and almost always by the following day, the tenderness has disappeared, the burnt spot has lost its extra red colour, and the appendages of the papilla? begin to form again. Such burns as these seldom call for treatment ; but if the soreness of the tongue continues longer than usual, borax and honey may be painted over the burnt area, or an astringent lotion may be used, or a gargle of chlorate of potash at frequent intervals until the annoyance ceases to be felt. The severest burns are those which are produced by chemical agents, by the mineral acids, the caustic alkalies, and corrosive sublimate. In these burns the tongue rarely suffers so much as the back part of the mouth and fauces. Indeed, in many cases, the fluid is thrown so far back in 40 DISEASES OF THE TONGUE. the mouth that the tongue escapes almost untouched. When the tongue has been touched by the material, the effect is not usually that which would be produced by simple extreme heat, but varies according to the material which has been used, and partly with the length of time during which the tongue has been in contact with it. Thus : Corrosive sublimate produces in most instances a very characteristic condition of the tongue, which is white and shrivelled, with great enlargement of the papilla at the base. In sulphuric acid poisoning the tongue is usually white and glazed, and the surface looks sometimes like soaked parchment, sometimes like white paint. In a short time it becomes grey or brownish-grey, is much swollen and often excoriated. In nitric acid poisoning the tongue is generally swollen and of a citron colour; the mucous membrane is soft and easily peels off. In hydrochloric acid poisoning it is also swollen and often dry. After oxalic acid has been taken it is generally swollen and covered with a thick white coat, as if it had been scalded. Carbolic acid renders the mucous membrane white and hard. Potash and soda soften the mucous membrane, which is easily detached. The tongue, in poisoning by these caustics, is often bluish-red, or may be yellowish-brown. Ammonia colours it white, and excoriation is common when either of the three has been taken. The other poisons, as a rule, produce no alteration in the appearance of the tongue in cases of acute poison- ing. Almost the only exception is the tincture of cantharides, which causes the tongue to swell and produces excoriation. It need scarcely be remarked that the action of most of these powerful irritants and caustics is not limited to the tongue, but is apparent on all parts of the interior of the mouth. The appearance of the tongue is thoroughly characteristic only in poisoning by corrosive sublimate. In such a case the white and shrivelled aspect of the tongue lll'li.\s AM> SCALDS. 41 may be of great value in attempting to discover the poison which has been taken. Scalds of the tongue and of the whole of the interior of the mouth are not very uncommon, especially in chil- dren : and in children of the lower orders they are fre- quently produced by an attempt on the part of the child to drink out of the spout of the kettle. Usually only a very small quantity of the fluid enters the mouth, but the tiny drop of water and, much more, the steam, are sufficient to produce disastrous consequences. The effect on the tongue, however, is one of the least of these. The real danger to life lies almost always in the damage to the air passages. The tongue swells and becomes for a while exceedingly painful and tender, so that the taking of food in any form is difficult. The surface of the tongue is very red, and sometimes blebs are formed. The swelling and distress, so far as the tongue is concerned, rapidly pass off, and the patient is often able to swallow without obvious discomfort in the course of a few hours. Yet no direct treatment is adopted for the relief of the buccal scald, partly on account of the difficulty of carrying it out in the cases of young children, partly, and probably chiefly, because it is notorious that the buccal trouble rapidly subsides with- out direct local treatment. The warm and moist atmosphere which is usually maintained in the immediate neighbourhood of these little patients may have something to do with the rapid recovery of the mouth ; but probably the youth of the patients and the excellence of the interior of the mouth as a sick chamber for the injured parts have more to do with it. It has been suggested that the blebs which sometimes form upon the tongue and over the interior of the mouth should be broken down with the linger; but we have never seen a case in which this appeared necessary or in any Avay likely to relieve the patient. Slight burns in the mouth occur in adults smoking cigars or cigarettes. The size and depth of the burn is apparently most trivial, yet chronic ulcers have followed from which malignant disease arose, or the scar after healing has years later been the seat of epithelioma. Such a growth commenced on the tongue of a woman where a drop of 42 DISEASES OF THE TONGUE. caustic potash had fallen a long while before. This tendency is a great reason for not using the actual cautery to slight affections of the tongue. At an inquest held at St. Bartholomew's Hospital on a woman, aged thirty-eight, who had been given to drink, it transpired that she had bought a halfpennyworth of gun- powder, put it into her mouth, and set fire to it. On enter- ing the room, which was full of smoke, the woman was found rolling on the floor. Blood was oozing from her mouth, and the tongue and roof of her mouth were blackened. She died the next day. Eichhorst mentions the case of a lighthouse-keeper who was looking up at the burning lighthouse when he received fatal injuries from a stream of molten lead which fell into his mouth and down into his stomach. In adults the pain of small burns in the mouth may be relieved by sucking ice, also by painting on a solution of cocain. 2. Stings and Bites of Insects and Reptiles. The results of stings and of the bites of reptiles are referred to in the chapter on Inflammation. The tongue is very rarely bitten by reptiles, but instances have been recorded in which snakes have been incautiously handled, and a bite of the tongue has been the result. The effect will then vary according to the poisonous or non-poisonous character of the snake. Stings of insects are much more common : the insects are taken into the mouth con- cealed in fruit, and serious injuries have in this manner been produced by wasps, bees, and other stinging insects. The bite may prove fatal within a few minutes if the tongue is the bitten part, on account of its vascularity and its large lymphatic supply ; or the inflammation abates without actually producing the threatened suffocation, and the patient is speedily relieved. An indurated patch has marked the site of the sting for some time. Gangrene and suppuration are equally unusual events in the course of these inflammations, however severe they are. The patient immediately becomes faint, then collapsed and unconscious, and the respiration rapidly fails. In a less severe type acute oedema of the glottis follows upon the swelling of the tongue, and tracheotomy is necessary to save life. SITES OF THE TONGUE. 43 The treatment does not differ materially from that which is proper in other cases of acute parenchymatous inflam- mation, but incisions are very seldom needful. F. Clarke recommends that the mouth should be very frequently washed out with an alkaline solution in the hope of neutralising the formic acid, which is the active principle of the poison, and he gives the preference to a weak solution of ammonia. It would be more effectual to inject a weak solution of ammonia into the site of the sting. Active treatment will also be required if the patient is collapsed. 3. Wounds of the Tongue. The commonest wounds are those made by the teeth. Severe wounds are occasioned by bullets and by teeth or pieces of the jaw driven into the tongue. There are also cases in which a pipe-stem has caused fatal injuries. (a) Bites of the Tongue. As a rule, bites of the tongue are not serious accidents, but cases are on record in which they have been the cause of death. Dr. Wickham Legg has recorded cases of haemophilia in which a bite of the tongue proved fatal from continuous haemorrhage. Severe bites are occasioned in the course of epileptic tits, also during puerperal eclampsia. During the stage of clonic movements the tongue is forcibly protruded, and immediately following this the jaw closes. In the College of Surgeons' Museum, specimen No. 2,266, is the tongue of an epileptic idiot, aged sixteen, who bit off the end of his tongue in a fit. Haemorrhage occurred for two days, the mouth became foetid, sloughs formed, the patient became weaker and died. The specimen shows that both ranine arteries had been divided. Epileptics have been found in the morning pulseless from severe haemorrhage, having bitten the tongue during sleep. So also in puerperal eclampsia severe injury to the tongue may occur unless the patient is watched. Many severe bites have occurred in children from falling on the chin. Fatal haemorrhage was occasioned in a child aged fifteen months who fell out of a chair; there was a tendency to profuse bleeding in other members of the family. Hobbs saw a man who was working with his tongue out, when he was struck under the chin and nearly bit his tongue oft', but it united well after suture. An extraordinary 44 DISEASES OF THE TONGUE. occurrence from a medico-legal standpoint is reported by Makima. A drunken man seized his father by the throat, so forcing him to protrude his tongue, which he seized with his teeth, inflicting a deep jagged wound. Another curious bite was seen by Nregeli in an old woman with a single pointed incisor, which had transfixed and held forwards the tip of the tongue, causing grave trouble with deglutition. The tongue may be severely lacerated by a compound fracture of the jaw. Norgate saw a young man who had been so severely crushed by a waggon-wheel that the tongue had been almost severed at its base by the sharp edge of the fragments of the lower jaw. Only a few shreds had to be divided in order to complete the amputation. The bleeding was free, but not severe, and healing took place quickly. In order to prevent a person in a fit biting his tongue a piece of stick or handle of a knife or spatula is pushed between the teeth. An interdental splint has been devised to be worn by epileptics at night to prevent tongue-biting. In all cases, however lacerated and however small the con- nection, an attempt should be made by suture to fit the lacerated, portions accurately into position. When there is no displacement of the bitten-off tip there is no special indication for suturing. Horsehair sutures may be inserted after cleaning the wound and ligaturing any bleeding point. This may be done under cbcain, or chloroform may be required. Afterwards a mouthwash of permanganate of potash should be constantly used. Liquid food will be required for a few days. The horsehair sutures are left till they drop out or become loose. If seen later the edges of the wound should be pared, and the refreshed surfaces sutured together. (6) Hcemorrhaye from Wounds of the Tongue. To speak once for all of the haemorrhage from wounds of the tongue which is not due to the presence of foreign bodies, it should be a rule of practice to arrest the haemorrhage thoroughly as soon after the accident as possible. If the wound is far forward, there is usually no difficulty in doing so ; but if the wound is far back, a difficult and serious operation may be required. In such a case let the bleeding HEMORRHAGE FROM THE TONGUE. 45 be temporarily arrested by the pressure of the finger on the wound, or a piece of lint or gauze between the linger and the wound until the measures for the permanent arrest have been considered and arranged. Then place the patient in a good light, administer chloroform if possible, and open the mouth thoroughly with a strong gag, draw out the tongue by two stout threads passed through its tip, one on either side, and carefully examine the wound. The time lost in these manoeuvres is in most cases time gained, for the loss of blood during them will be much less than if half measures are adopted, and the chances of permanently arresting the haemorrhage are vastly increased. If, when the wound is thus exposed, a bleeding vessel can be seen, it will of course be ligatured ; but if blood wells up from a deep and perhaps almost punctured wound, the wound should, without hesitation, be enlarged until the vessel is in view. If on examination it appears certain that the hemorrhage is not arterial, but is the result of general oozing or of wounds of veins, the bringing together of the edges of the wound by deep sutures, after the clots and other matters have been removed, will suffice to arrest the bleeding. In all cases of haemorrhage from the tongue, when the haemorrhage is thought to be arterial, it must be borne in mind that the larger arteries are deeply placed. They cannot be wounded by a superficial incision, and a punctured wound will have to be followed up to a considerable depth. Ligature of the lingual artery in the neck is, however, very rarely needful in cases of primary haemorrhage from the tongue. It may be objected to the practice which has just been recommended, that although it is not difficult to carry out in a large hospital or in a large city, where the necessary instruments and the requisite assistance can be certainly and speedily procured, the case is far otherwise in a small town or a widely-extended country practice. This is quite true, and, in the latter case, if the hemorrhage is so severe as to threaten life, so much the worse for the patient. Yet, even in these conditions, much may be done to avert the catastrophe by timely and sensible measures. A surgeon, single-handed, or with lay assistance, may examine the wound, turning out the clot, and cleansing the surfaces in 46 DISEASES OF THE TONGUE. a thoroughly good light, and he may succeed in finding and putting a ligature round the bleeding vessel, particularly if the patient has fortitude enough to remain quiet during the necessarily painful and tedious operation. But if this fails, and the bleeding still continues, the best hope is in pressure, kept up as long as may be necessary by the finger of the patient or some other person on a strip of gauze thrust deep down in the interior of the wound. By this means the haemorrhage may at least be arrested until further assistance can be procured. Secondary haemorrhage is very unusual from simple wounds of the tongue, unless they are complicated by the presence of foreign bodies. It is then fraught with the most serious danger to the patient, and may not improbably end fatally. In this case, as in the case of primary haemor- rhage, the only reasonable chance of success lies in the complete exposure of the wound and an examination under favourable conditions. If this is desirable in dealing with primary haemorrhage, it is doubly desirable in treating secondary haemorrhage, for all the difficulties are increased. If the bleeding vessel cannot be discovered, or if it is in such a condition that a ligature cannot be applied, severe and repeated secondary haemorrhage may necessitate ligature of the lingual artery. And, when the wound is far back in the tongue, and implicates the tonsil or other of the adjacent structures, the question may arise of ligaturing the external or even the common carotid artery. Traumatic fissures and ulcers of the tongue are described in Chapter IX. (c) Bullet-wound of the Tongue. Rifle bullets of high velocity are mostly fatal owing to the extensive laceration of the tongue and the wounding of the large vessels in the neck. The cases caused by bullets of low velocity from inferior pistols mostly come under the notice of the surgeon. The bullet may lodge in the tongue and be extracted with difficulty, or in the pharyngeal wall, or it may drive a tooth in front of it. In Baker's case a probe passed into the wound of entry on the dorsum of the tongue, and came out in the pharynx just in front of the epiglottis. Six days afterwards the bullet was passed per anum. Range describes PERFORATING WOUND. 47 the case of a child, aged four, into whose open mouth a boy tired. The bullet passed through the base of the tongue and pharynx, and buried itself in the neck in the region of the sixth and seventh vertebrae. Severe haemorrhage occurred on the sixth day, Avhich was followed by an abscess dis- charging into the pharynx, and following this there was suppuration deep in the neck. The illness lasted three months, and healing finally took place without the bullet being recovered. The treatment of bullet-wounds includes the removal of the bullet or tooth, if possible, always re- membering the classical rule, of being prepared for a gush of blood on extracting a foreign body. Deep-seated haemor- rhage might require ligature of the lingual in the neck. (d) Wound of the Tongue and, through it, of the In- ternal Carotid Artery and Jugular Vein by a Pipe-stem. Two remarkable cases occurred almost at the same time in two London hospitals. A man, aged twenty, was admitted to Guy's Hospital, under Bransby Cooper. Three days before he had been smoking, when the elbow of a companion struck the bowl of the pipe and drove the stem into his tongue, breaking off three inches. He fainted on account of the pain, and a surgeon found a wound passing obliquely from the right to the left side, which he probed, but struck nothing. No bleeding occurred, but he sought admission for increasing swelling of the tongue and throat, which im- peded speech and swallowing. On the fifth day the swelling was less, and the wound noted in the tongue had closed. On the sixth day he vomited a pint of blood, and this vomit- ing recurred, so that by the twelfth day he was very anaemic. No wound could be made out in the mouth from which the blood could come, but there was still considerable swelling of the tongue and fauces, and the jaw could not be opened widely, so that the view was very incomplete. He continued to vomit blood, and died on the fifteenth day, after bringing up blood and clot. Post mortem : The wound had transfixed the tongue from left to right, and both openings had closed, but in the track of the wound within the tongue was a piece of pipe-stem two and a half inches in length. Opposite the wound of exit on the left side was a small irregular opening, just behind and below the left tonsil, from which injection 48 DISEASES OF THE TONGUE. material came freely when the carotids were injected. This was doubtless from the internal jugular, as the clinical course of the case indicated ; but there was no dissection made to clear up the point. A curiously similar and more startling case occurred to Hamilton at the London Hospital. A man, aged thirty, was smoking, when he i'ell and drove his pipe- stem into his tongue. The tongue began to swell, and gargles were used. On the fourth day he was taken to the London Hospital, with the tongue enormously enlarged. The dresser lanced the tongue and let out an ounce of pus. As the respiration became increasingly difficult, Hamilton was sent for, who probed the abscess cavity and struck the pipe-stem, and, seizing it with forceps, pulled out a length of four inches. This was followed by a torrent of blood, and the patient died in less than a minute in spite of the compression of one and then of both carotids. Post mortem : It was found that the pipe-stem had entered the right tip of the tongue, had emerged on the opposite side near the root, and then, passing beneath the left tonsil, had gone completely through the left internal carotid and internal jugular vein. 4. Foreign Bodies in the Tongue. (See also under " Actinomycosis.") In connection with the last section, it will not be amiss to draw attention to the symptoms produced by the presence of foreign bodies in the tongue. When the nature of the accident has rendered it possible that a foreign body has been embedded in the substance of the tongue, it is scarcely necessary to say it should be A T ery carefully sought for, and removed as speedily as possible. But it sometimes happens that a foreign body is not sus- pected, and, either on account of its small size or of the depth at which it lies, there is no hardness over it. It remains embedded, and for a long time unsuspected, but the wound does not heal. In the course of a few days the first serious symptom may be a slight attack of secondary haemorrhage, and this alone ought to excite suspicion. If haemorrhage occurs it is generally repeated, and if the body is not soon extracted and the source of the haemorrhage discovered and treated, a serious termination of the case may result. In the absence of haemorrhage, inflammation may be excited by the !' REIGN BODIES. 49 presence of the body, and a hard, circumscribed, indolent tumour is formed, through which a sinus sometimes leads down to the exciting cause. In some cases, much more severe inflammation is excited, suppuration occurs, openings are formed, and sinuses remain, through which fungous granulations protrude. Under these circumstances the foreign body may be spontaneously discharged, especially if it is small. But it rarely excites so much disturbance, and more commonly remains buried in the indolent inflammatory tumour which has been formed around it. Many cases are on record in which a foreign body has remained thus hidden for several years, and sometimes the symptoms have been very singular. Perhaps no case is more interesting in this respect than one which is quoted by Legouest from Manget of a person in whose tongue a ball had been embedded six years before it was removed. During the whole of the six years the patient stammered excessively, and the stammering ceased after the removal of the ball. Seller relates a case which is worthy to be borne in mind. The patient Avas a man, twenty-eight years old, who had suffered from soreness of the throat, cough, slight hoarseness, difficult and painful deglutition, and white, starch-like expectoration for several weeks, and who was growing worse. He was examined with the laryngoscope, and the usual appearances of chronic laryngitis were observed; but, in addition, a thin, glistening- needle-like body, protruded about half an inch from the sur- face of the tongue, near the glosso-epiglottic fold. The body was easily removed with a curved pair of forceps, and proved to be a bristle of a tooth-brush, somewhat swelled by long- maceration. The symptoms of laryngitis quickly disappeared. Gibb, guided by the laryngoscope, in 1866 removed a needle from the base of the tongue of a woman. Weber discovered a fishbone in the middle of a scirrhous tumour. Anderson says that the amber mouth-piece of a pipe remained unsuspected lor a month in a man's tongue. The man had jumped into the water to save another man from drowning, and thought that the injury to his tongue had been due to his striking his chin. It was only atter the extraction of the mouth-piece that he remembered that he hail been smoking a pipe at the time and had not taken E 50 DISEASES OF THE TONGUE. it out of his mouth before he dived into the water. Fork relates that a Prussian soldier had his teeth driven into his mouth by a bullet at the battle of Grossgorschen on May 2nd, 181.3. On the thirty-second anniversary of the battle a swelling appeared on the tongue, from which the second lower molar, which had been embedded all that time, was extracted. Potter tells of an officer who, at the battle of Harper's Ferry, was struck by a Minie bullet, which knocked in his teeth, and very severe haemorrhage followed for a week. Then there was found under the tongue a wound, at the bottom of which lay a molar tooth. This was extracted, and the ranine artery tied. The officer recovered, and was killed leading his brigade at Gettysburg. A foreign body may be suspected if a wound, especially a punctured wound, does not heal readily. The sinus should be examined with a probe, when the presumption rnay often be exchanged for a certainty. But the wound of entry may readily heal over a foreign body, which then forms an indolent swelling. In such a case it may resemble an encysted calculus, or a tumour. The history of an accident with the loss of a tooth, etc., may aid ; otherwise, the diagnosis cannot be completed until the tumour is explored. The extraction of a foreign body should never be under- taken except after due preparation for possible haemorrhage, 'the patient anaesthetised in a good light, the mouth well open, a thread passed through the tongue, and assistants at hand. 5. Acquired Ankyloglossia or Tongue-tie. This is the result of extensive ulceration and sloughing, of which two causes are now less active than formerly viz. mercurial glossitis and septic inflammation. It was the custom of administering mercury freely in the course of specific fevers that often led to this sloughing. A number of cases are mentioned following small-pox. Roland de Belebat describes the almost complete loss of the projecting portion of the tongue in a young boy in the course of an attack of small-pox, recovery taking place, and the boy ulilc to speak well. Boddington gave an account in the " Philo- sophical Transactions " of " Margaret Cutting, who speaks intelligibly although she has lost her tongue." But it is rather the adhesions which have formed between extensive AXKYLOGLOSSLL 51 ulcerating surfaces which have caused the tongue to become fixed. South says of a case: "After severe sloughing, follow- ing the use of mercury, the side of the tongue was attached to the cheek for the extent of half an inch. A ligature was applied round the band, which cut through in three or four DISEASES Oh' TIIH TOM I' I:'. 0. The Results of Removal of Part of the Tongue. The splitting of the tongue, or the removal of the front part by seizing it and cutting it off with a knife, tearing it off with pincers, or burning it off with the cautery, was a cruel form of punishment directed against free speech. It con- tinued in Europe until the last century, and in the East until the present one. It was largely employed in religious per- secutions, and Fairlie Clarke describes the manner in which it was accomplished. There are also old pictures representing the sufferings of the martyrs. Much remark was excited by the fact that speech was completely recovered after these mutilations owing to the removal affecting only the anterior part of the tongue. The removal of a portion of the tongue by surgical operation is not followed by any marked impair- ment of speech so long as the projecting part of the tongue only is involved. It is a drawback to extensive operations on the base of the tongue and floor of the mouth that speech and swallowing of saliva and food are impaired. 7. Acquired Excessive Mobility (enabling the tongue to be projected into the nasopharynx). A curious series of cases has been described, all practically identical, yet the widely distant position of the observers and the impossibility of one patient having heard of a previous case, force one to believe that the mobility has been acquired quite spontaneously with the object of obtaining relief from a chronic and tiresome affection. Jurist, Wherry, Bourdette, Winslow, and others were the observers. The patients have all beeu young adult men suffering from marked atrophic rhinitis and pharyngitis, who, after continuous efforts extending over some two months, have been able to curl back the tip of the tongue and project it into the nasopharynx. The tip of the tongue could thus lick the nasopharynx, and the patients felt much relief by the moistening of the surface and the removal of the sticky mucopus and crusts. With the tip of the tongue the patients could feel the posterior nares and the orifices of the Eustachian tube. No drawback was experienced from this incn-ascd mobility; the fra>num was, of course, much stretched, and one or two patients said they had felt cracks in it whilst trying to curl the tongue back. 53 CHAPTER IV. S KM KIOLOUY. DISCOLOR ATIONS. Production of Appearances The Fur ou the Tongue The Stippled or Dotted Tongue The Coated, Furred, or Plastered Tongue The Dry Brown, Shrunken Tongue The Bare Red Tongue: () the Raw Tongue; (li) the Dyspeptic Tongue ; (<) the Hectic Tongue ; (d) the Senile, Wasted Tongue Xerostomia I'silosis or Sprue Discoloratious : (a) Xanthelasma ; (b) Addison's Disease: (<) Black Pigmentation : (d) Blood-stains Tinctorial Discolorations and Stains with Caustic Varicosity of Raiiiue Vein and Artery in relation to Cerebral Congestion. 1. Production of Appearances on the Tongue. In order to clear the way for a consideration of the local affections of the surface of the tongue, it is necessary to consider in this chapter the signs which the tongue exhibits in general disease, the formation of the fur on its surface and the raw surface left by the detachment of the fur, also the variations in the size of the tongue in relation to the circulation. The signs which the tongue exhibits in re- lation to nervous disease will be considered in a later chapter. The results of everyday observations on the tongue are still extremely indefinite, although attempts have been made from the earliest times onward to collate the signs exhibited by the tongue with particular diseases as distinguished from constitutional states, and to make the tongue serve as an aid in the diagnosis of disease. Even in diseases such as scarlet fever or rheumatic fever the typical appearance may be entirely absent. The tongue is in no way a trust- worthy mirror of alterations in the mucous membrane of the intestinal tract. Cancer of the stomach in the earlier stages causes no change in the tongue ; the appearance of the tongue in a disease like typhoid fever varies from time to time, according to the constitutional state through which the patient is passing. 54 I > I* EASES OF THE TONGUE. The formation of fur on the tongue and other changes are favoured by local conditions of which due note must be taken. The tongue is dried by breathing through the i n< uth, whether this be due to temporary or permanent nasal obstruction or to debility and unconsciousness. The formation of fur may be favoured by the loss of teeth, by the presence of a plate in the mouth, and a patch of fur may form opposite a gap from which one or two teeth have been lost. Furring is favoured by disease of the tongue, whether inflammation, ulceratiori, neuralgia, or pa- ralysis, also because the patient does not take solid food to rub it off. A diminution in the amount of saliva secreted favours the formation of fur a diminution which takes place in the course of fever from whatever cause. The saliva does not appear itself directly to hinder the growth of organ- isms, but indirectly by favouring the formation of leu- cocytes in the tonsils and other glands, which cells hinder organismal growth. Diminution in the amount of saliva may not be the only thing which takes place in febrile affection, and there may be variations in the chemical composition of the saliva. (Hugenschmidt.) The size and shape of the tongue is connected with the circulation. The size of the tongue varies with the blood pressure, as is most strikingly shown in cases of extreme thirst, in which the tongue shrinks as the pulse fails. Variations in the composition of the blood tending to anaemia produce the pale, flabby tongue ; and if there is u'dema, the tongue is easily indented by the teeth (see PI. I, Fig. 2). In acute fever with high pulse tension, the tongue tends to become bright red, whilst it becomes bluer with cyanosis. 2. The Fur on the Tongue. The fur on the dorsum of the tongue, whether in health or in disease, is composed partly of epithelial scales and of debris of the food, but especially of micro-organisms. A description of these micro-organisms was laid before the Royal Society, and was published in a separate paper in the "St. Bartholomew's Hospital Reports," 1879. (Butlin.) The subject has been since dealt with by Mr. Hutchinson in his I-' I 'It ON THE TOXGt'K. 55 lectures at the College of Surgeons in 1883, and by Dr. Dickinson at the College of Physicians in 1888.* The examination of the fur scraped off the tongues of a large i mi uber of persons showed that in every case organisms were present, micrococci, also bacilli in threads or forming spores, spirochieta, vibrios, and yeast organisms. The masses of mirrococci appeared to form the bulk of the fur, and were attached very tirrnly to the imbricated scales of the filiform or hair-like papillae. Sections of the tongue examined under a microscope showed that the micro-organisms were always attached to the filiform papilla?, and were seldom to be seen in the depressions between the papillae or on the fungiform or circumvallate papillae. When the fur is thin and the tongue is scraped tirmly, the amount of epithelium removed is proportionately great. When the fur is thick, and can be easily removed without much force, the mass chiefly consists of micro-organisms. The quantity of food debris, of course, varies, but does not compose much of the fur. A certain amount of fur, varying in individual cases, is not incompatible with the soundest health, especially on the dorsuin in front of the circumvallate papillae. The fur is limited to those portions of the tongue which are covered by the fili- form papilla?. When the tongue is lightly coated, so that the fur does not form a continuous layer, it is plainly discernible that the fur adheres to the filiform papillae and does not lie in the depressions between them. In such cases the fungiform papilla? are small, clean, and apparently sunken below the fur, but easily perceived. When the fur is so thick as to form a continuous layer, the fungiform papillae are sometimes hidden, but this is by no means invariably the case ; they can often be distinguished in breaks in the continuity of the coating. When the fungiform papillae happen to be congested, as in scarlet fever, they stand out like the tiny berries of * Dr. Dickinson, in his " Lumleian Lectures,'' considers the parasites which, to my mind, form the bulk of the fur, as "only of secondary interest." He regards the parasites as " the fringe of the garment rather than the garment itself." As I have always looked on the " fur " on the tongue as the fringe of the garment, and not as the garment itself, it is only reasonable that I should regard the parasites which make up the bulk of the fringe as the chief and most important constituent of the "fur" on the tongue. I, therefore, maintain, without any modification, the views which I put forward in 1879. If. T. B. 58 DISEASES OF TllK TONGUE. a strawberry in the midst of a thick layer of white or whitish yellow fur. The circumvallate papilla;, like the fungiform papilla-, are very seldom covered with fur, and the dorsuni behind the circumvallate papilhu has no fur on it, for it is destitute of papilla*. The tongues of very young infants, which are possessed of small and insignificant filiform papillae, are naturally almost or quite without fur; the fungiform papilla;, which are earlier developed than the filiform, and are com- paratively large and prominent, are smooth, so that the masses of organisms do not collect upon them. When the filiform papillae have been removed by previous superficial glossitis, not a particle of fur may be visible, or merely tiny patches where the papillae have not been quite destroyed and there is something to adhere to. In adults in health, fur forms during the night to a greater or less extent, according as the conditions are favourable to its development. In the morning almost every person has a very thin layer of fur over the papillary surface of the dorsum. During the day the greater part of this layer is cleaned off by the mastication of food, the movements of the tongue, the rubbing of the tongue against the roof of the mouth and teeth, and the actual washing of the mouth and teeth. The area most difficult to. clear by these means is the area immediately in front of the circumvallate V, for this area cannot be pressed against the roof of the mouth and teeth and is less moved than any other part of the dorsum on which fur collects. This area, therefore, is scarcely ever free from fur, unless the filiform papillae are deficient naturally, or have been removed or destroyed by disease. It is upon this area that the filiform papilla? sometimes grow to an inordinate length, whilst masses of micro-organisms cling to them and stain them a dark colour, producing the black, hairy tongue, to be after- wards described more particularly. From this area the fin- extends during the night, or when the tongue is not kept thoroughly cleansed. Free mobility is essential to the thorough cleansing of the tongue. Stiff and unyielding tongues are scarcely ever clean. The fur, then, is largely produced by the free growth of colonies of micro-organisms which have not been mechani- cally removed. Shed epithelial cells also compose a certain I'l'URED TOXGTE. 57 amount of the fur, and this, with the apparent overgrowth of the filiform papilla?, has given rise to the supposition of an excessive production of epithelium. There is very little evidence of an excessive growth of epithelium and of the filiform papilla- as distinguished from an undue retention of epithelium as far as regards the production of fur. Local diseases of the tongue produce an excessive growth of epithelium, but this is distinct from the production of fur, and a comparison of the processes tends to negative the view that there is an excessive production of epithelium when the tongue is furred. The appearance of the tongue in health varies very widely, some individuals having usually a considerable amount of fur ; in others the tongue is quite destitute of fur, even having a raw look. On the other hand, a normal tongue may be met with in both acute and in exhausting diseases. 3. The Stippled, or Dotted Tongue. This appearance is produced by a thin fur covering the filiform papillae, whilst the normal or congested fungiform papilla- show through or project above the fur. They be- come brightly injected, along with the similar injection of the skin in scarlet fever, and they become bluish whenever there is an increased venosity of the blood. Whilst quite consistent with health, a stippled tongue is commonly seen in slight disturbances, with or without fever ; it is common in children and in those taking liquid food. 4. The Coated, Furred, or Plastered Tongue. This tongue is particularly seen in acute cases attended with fever. In the early stages the fungiform papilla^ still appear through the fur, then the whole surface is covered by a yellowish-white fur, which gets browner and drier as the patient becomes more exhausted. If the patient improves the fur gets thinner and moister towards the edge, where the fungiform papilla 1 reappear, and as the tongue cleans, a streak of yellowish or brownish fur is at last left down the middle of the dorsum from the V forwards. Then the tip cleans, and finally the rest of the dorsum. The longer the fur remains without becoming dry the more shaggy it becomes from the accumulation of organisms on the filiform papilla?. A thick fur often accompanies slight disorders of the 58 DISK ASK* OF THE TONGl'K. stomach and intestines, such as may be produced by free eating and drinking overnight, and popularly, the lining membrane of these organs is supposed to be in the same condition as the tongue. There is no evidence that this is the case. The fur is the effect of the diminution of the amount of saliva secreted, perhaps also to alterations in its composition which, along with the malaise, are probably caused by abnormal substances in the blood derived from the alimentary canal. The most thickly plastered tongue is seen in acute rheumatism, but no reliance can be placed upon this yellowish-white fur for diagnostic purposes. Unilateral furring is generally the result of disuse and consequent arrest of cleaning by rubbing. This may be due to paralysis, to neuralgia, painful ulcer or sharp tooth, preventing movement which causes pain ; also the discharge from a carious tooth is an additional stimulus to the growth of organisms. 5. The Dry, Brown and Shrunken Tongue. This is the tongue characteristic of an exhausting illness, whether rapid or slow. The tongue may have passed through a stage of moist furring, but in certain conditions, e.g. septic peritonitis, the tongue in a day or so becomes dry and shrunken.. Brown, dry crusts may cover the surface and hide the papilla--. Fissures tend to form, sometimes irregular cracks, sometimes deep transverse fissures, with longer and shallower longitu- dinal fissures, making the surface of the tongue resemble crocodile skin. Similar crusts or sordes cover the teeth and lips, they consist of inspissated mucus, in which are embedded masses of micro-organisms, yeast organisms, etc. What saliva there is in the mouth is sticky. The tongue is shrunken owing to the failing pulse tension, and continues to shrink to a hard, scarcely mobile mass, as the pulse tension further falls. The secretion of saliva is reduced to a minimum, whilst there is not enough muscular force to keep the jaw closed, or the patient is unconscious, so that the mouth dries by evaporation. This state of the tongue may be produced by extreme thirst, by acute diarrhoea and cholera. In typhus fever the tongue is described as becoming black. It is seen in the later stages, of intestinal obstruction, typhoid fever, septic peritonitis, in IIMIE RED TO Mil'l-;. 51) insufficiency, heart failure, the latter end of phthisis, and in cerebral affections, delirium, mania, etc. Such patients are said to be in an " asthenic " condition, and are like to die. If, however, the edges and tip of the tongue commence to become moist, and the crusts to separate, an improvement in the state of the patient is indicated, improved action of the kidneys, cessation of the delirium, etc., etc. (i. The Bare, Red Tongue. The tongue appears not only free from fur, but the epi- dermis is extremely thin, owing to the early loss of the superficial corneous layers, including the filiform papilke. In the more severe cases the tongue may, in addition to being bare and red, be dry, cracked and shrunken. Such a tongue has to be distinguished from slight cases of local disease, such as .superficial macroglossia, tertiary syphilis (inherited or acquired), chronic glossitis from tobacco smoke. (a) The Raw Tonyue. In some subjects the corneous layers are naturally extremely thin, and the tongue has been compared in appearance to a raw beefsteak. The patients have had the tongue with the same look as long as they could remember, and no inconvenience is caused except, perhaps, a slightly increased sensitiveness. (6) The Dyspeptic Tongue. A bare, red tongue is seen in some patients suffering from chronic dyspepsia, especially in women. It varies with the symptoms, and disappears when the dyspepsia is relieved. It is apparently due to reflex nervous irritation ; but it is also possible for dyspepsia to origi- nate a true chronic glossitis, as will be mentioned later. (c) The Heel ic Tongue. The bare, red, often dry, shrunken, and cracked tongue is characteristic of long and exhausting illness, attended by prolonged suppuration, where there is chronic septic absorption or "hectic." Hence it is seen in chronic empyema, tropical liver abscess, chronic dysentery, advanced phthisis, diabetes. It may follow upon any con- dition which results in chronic pyaemia. If crusts form they separate, leaving a smooth, raw surface, covered by the deepest layers of epithelium only : the tongue loses much of its mobility, and becomes quite hard on palpation. If the chronic septic absorption is arrested the tongue begins to get moister at the edge. ^ 60 DISEASES OF THE TOXGI'K. (d) The ,sV,//7r 1IW,-,/ TOIXJIK'. In old women and others who, although not old, have been exhausted, the filiform papilla) may as nearly as possible disappear, leaving a few of the fungiform papillre and the circumvallate ones. The filiform papilla; appear to be shed like the hair. But such tongues may be seen drier than normal, slightly excoriated, tender, and then fall into the next category xerostomia. 7. Xerostomia. A series of clinical cases has been met with by Hadden and others in which, in consequence of a diminished secre- tion of saliva and mucus, there arises persistent dryness of the mouth and tongue. The trouble is apparently nervous in origin, and affects, in nearly all cases, women past middle life, half the cases occurring after fifty years of age. It occurred in men in four cases out of thirty-nine. The mouth and tongue are chiefly affected, but in one-fourth the nose, and, in a rather smaller number, the conjunctive likewise suffered Irom dryness. It is seen especially in neurotic women whose health has not been good, and it consists both in a diminished secretion and in a senile atrophy of the glands. It occurs at a later stage than atrophic rhinitis and pharyngitis, in which anaemia plays a great part, and in which the tongue and mouth remain free. Sometimes a vague illness, such as influenza, has been the commencement of the complaint : in others, mental shock or wony. The parotid glands have been found swollen and tender in some cases, not so the other salivary glands. The lips become dry and scaly, the tongue dry, smooth, dull red, the surface like crocodile skin, or fissured and cracked like eczematous hands, the filiform papilke absent, the fungiform papilla? prominent. The gums, cheeks, and palate are dry and glazed, or may be covered with crusts. There is a salt taste in the mouth, but the taste for food is lost, although a strong solution of quinine may be recognised. The teeth are generally carious, or slowly crumble away. The secretions from the salivary papilla 1 may be very small or absent ; some patches of buccal glands may show moisture. If the nose is involved, the interior is dry with crusts: if the eyes, only a yellowish, sticky fluid is found in the conjunctival sac, and the tears which can be made to flow ar^very scanty. The skin has DISCOLORATION^. 61 been noted to be very dry and harsh, and in other cases sweated rarely. This is a permanent affection for which little can be done. Tonics and douches, with the removal of carious stumps and fitting in of suitable dentures, form the general line of treat- ment. Attempts to excite secretion by pilocarpine seem to be as useless as it is to flog an exhausted horse. s. The Tongue in Psilosis or Sprue. Sprue is a chronic affection attacking men in the Straits Settlements, Batavia, parts of China and of India, including Ceylon. It is characterised by a "persistent diarrhoea, con- sisting of pale yellow, frothy, unformed stools, with special soreness of the tongue and gullet. The tongue undergoes marked variations, returning to the normal, then relapsing. (Thin.) The corneous layers of the epidermis separate, leaving the tongue red and bare, and, as the patient becomes ex- hausted, it is more cracked and fissured. If the patient improves the sides become moist, and there is a quick return to the normal. But this has to be closely watched for any indication of relapse. The disease is not dangerous if the patient can return to Europe before getting exhausted, and is young and not otherwise diseased. The redness and rawness of the tongue, the soreness of the gullet, and the loose stools quickly disappear on a milk diet, and a return to the milk diet is required if a relapse threatens. 9. Discolorations of the Tongue. Under this title will be considered discolorations of the fur, and areas of discoloration situated in the mucous and submucous tissues of the tongue, but the consideration of the white and bluish-white patches and plaques (leucomata) which characterise psoriasis, etc., also melanokeratosis, black tongue, or nigrities, will be reserved for another chapter. (a) Xanthelasma of the Tongue. Patches of xanthe- lasma have been only very rarely met with in the tongue. One of the best examples is that published in the "St. Bartholomew's Hospital Reports" by Dr. Wickham Legg. The patient was jaundiced, and, in addition to the jaundice, had xanthelasma of the eyelids and conjunctiva, of the palms of the hands, the left elbow, right ear and left side of the L> DISEASES OF THE TOXdl'K. nose. Along the sides of the tongue were yellowish- white oblong patches, quite soft, but slightly raised ; there was also a yellow spot of the same kind on the middle line of the roof of the mouth, and another near the lingual vein. The patches on the tongue were sharply defined, and varied in size from a split pea to that of a sixpence. Two of those near the tip showed a slight loss of substance, and were covered with a crust of blood. The microscopical examina- tion discovered, with a low power, narrow, long streaks of black immediately beneath the mucous membrane, and with a high power these 'black streaks resolved themselves into a great multiplication of the cells of the connective tissue, with fatty infiltration of most of them, appearances corresponding to those found in xanthelasma of the skin. (//) Black Marks in Addison's Disease. Persons suffering from Addison's disease not infrequently exhibit, in addition to the general discoloration of the skin, very dark or black marks on the mucous surface of the lips, the tongue, and other parts of the interior of the mouth. They look like mere stains of the mucous membrane, are sharply defined, neither raised nor depressed, and are usually situated on or near the tip and borders. They vary considerably in size. Fowler gives a plate showing inky patches along a narrow strip on each side of the tongue, with patches on the palate, inner side of cheek, and forehead. The presence of these dark patches in the interior of the mouth is not of much importance, clinically. They are always, apparently, associated with discoloration of the skin, and are, therefore, not likely to be very useful in the diagnosis of doubtful cases of Addison's disease. They produce no inconvenience, and in most instances the patient is not aware of their existence; they, therefore, require no treatment. (<) Pigmentation in Exhausting Diseases. Dr. Greenhow has described a case in which there were patches of bluish-black discoloration at the tip and on each side of the tongue, with brown patches on the inside of the lips and cheeks. These patches were precisely similar in every respect to those which BLOOD STAINS. 63 occur in Addison's disease. But there was no discoloration of any part of the surface of the body, and the marks had been noticed on the tongue three years at least. The nuin died of advanced pulmonary phthisis, and after death the supra-renal bodies were found to be quite healthy. Arnott made a microscopical examination of portions of the dis- coloured mucous membrane, and discovered that the pigment was present only in the corpuscles of the connective tissue of the papillae and of the submucous layer; whereas in Addison's disease the pigment occurs in the deeper cells of the epidermis, and little or not at all in the connective tissue. Danlos saw a case with a number of blackish patches on the buccal mucous membrane and on the left side of the tongue in a man who had not Addison's disease, but heart and kidney disease, with emphysema and bronchitis. He was in a miserable state, covered with pigmented patches, melanodermia, the result of phthiriasis. (d) Blood-stains are occasionally observed in purpura. Froriep has figured the tongue of a person suffering from purpura hseinorrhagica, and on the dorsum are two large blood patches, very black in colour. The illustration does not afford much idea of the actual condition of the tongue, for it was done many years ago, and is very deficient in artistic power and colouring. Ecchymoses may occur in and beneath the mucous membrane from other causes than purpura. As they dis- appear, they may leave behind brown and yellow stains, which are very slow in passing away. It is not improbable that the dark marks in the case described by Greenhow owed their origin to this cause. Blood- stains are, of course, easily distinguished ; whether they are the only disease present, or whether they are only a symptom of a general disease, they require no special treatment. The foregoing conditions are easily recognised, and can scarcely be assumed. The colour lies in the very structure of the tongue, and cannot be removed or greatly altered unless by destroying some of the superficial structures of the organ. Even the colours produced by caustics are much 106 DISEASES OF THE TONGUE. know, of care and anxiety. They may be observed on the tongues of quite young persons, but are not so frequent in them as in older persons : they are frequently due to the compression of a tongue a little too large to lie smoothly stretched out within the circle of the teeth. They are, therefore, in many instances, evidence of some past and, it may be, temporary inflammation, or hypertrophy, which has not completely subsided. All these furrows bear the same general characters of smoothness of the interior of the depression, a complete absence of fur, a complete absence of induration about their borders, and the possibility of removing or smoothing them away momentarily by drawing apart their sides. Their presence is not usually noticed by those Avhose tongues present them, and if it is noticed it is regarded as a curious phenomenon. Medical assistance is very rarely sought for their removal, and only by the highly nervous or eccentric. They are not amenable to treatment, nor is treatment needful. Inflammatory fwrroius are not uncommon in tongues which are the seat of chronic superficial inflammation, and they are still more common in tongues which have been the seat of deeper limited chronic inflammations, which, after subsiding, have left the tongue enlarged. Of this latter class the following is an example. A gasfitter had been accustomed to drink a tolerably large quantity of rum each day, until his tongue became affected, and to smoke two or more ounces of tobacco every week. About two years before he applied for relief at the hospital the fore part of his tongue had been swollen, red, and sore, and although he had abandoned smoke and drink, the inflam- mation had endured a long time, and had left the tongue permanently larger than it was before. A large segment ) chiefly of the front and right side of the dorsum, was swollen, and mapped out by numerous furrows, which, running over it in all directions, surrounded many small islands covered by perfectly smooth red mucous membrane. There was no ulceration of the bottom of the furrows, some of which were so deep and narrow that they might fairly have been termed fissures, and they could all be smoothed INFLAMMATORY FURROWS. 107 out by the pressure of the fingers on each side of them. He came, not on account of the furrows, but because he was so frequently annoyed by the soreness of the islets which they surrounded. By reason of their prominence they were perpetually subject to friction from the teeth and from the food passing over them, and so became excoriated and inflamed. In this and similar cases the furrows and the raised areas between them may bear no direct relation to each other, but be the results of a common cause, the compression of a portion of a tongue which is enlarged. The furrows can scarcely with precision be termed inflam- matory, for they are only an indirect result of inflammation, and might be due to hypertrophy from any other cause. True inflammatory furrows are such as have been described by Wunderlich in " Dissecting Glossitis." Demarquay speaks of the condition under the title of " chronic superficial glos- sitis," and. says that this dissecting glossitis resembles the papillary form of acute superficial glossitis (whatever that disease may be), from which it only differs in the depth of the furrows with which the surface of the tongue is covered. Demarquay speaks of it as a very rebellious malady, of which the cure is often incomplete, the surface of the tongue retain- ing almost always afterwards a more or less marnmilated aspect. An excellent example of this disease was in the tongue of a young man under the care of. Sir W. Savory, in St. Bartholomew's Hospital. He had been for some time a patient in the ward, and had submitted to amputation of the thigh. The progress towards recovery was slow, and was interrupted by a rather acute attack of superficial inflammation of the tongue, which did not affect its entire surface equally or in the same manner, but produced with great rapidity a large number of interlacing furrows, all of them very superficial, and many of them excoriated and very sore at the bottom. The surface of the tongue between them was smooth, redder than natural, and free from papilla? and fur. The appearance of the whole was not unlike that presented by an old painted door, which through age and exposure to the sun, has cracked and dried, so that its former smooth surface is broken up and mapped out by vast numbers of intersecting lines and furrows. It 108 DISEASES OF THE TONGUE. was thought at first that the disease was due to past syphilis, but there was no history of syphilis, and there was no other symptom to denote that the patient had ever suffered from syphilis. Further examination and consideration of the case led us to believe it to be an example of the more acute variety of superficial glossitis described by Demarquay and Wunder- lich, but differing in one respect from what may be called ''their" disease in the shallow depth of the furrows. Both diffused and limited inflammations of the surface of the tongue may lead to scattered furrows, which are often permanent, especially when they have been preceded by actual ulceration (Plate II., Fig. 1). Furrows which are due merely to compression of the tongue within too narrow limits can only be treated with success by such means as will reduce the enlargement, which is the prime cause of their existence. It is not usually the furrows, but the intervening areas, which we are called upon to treat, and the treatment fitted for them is such treatment as is needed in every similar condition of inflammation and excoriation of the surface of the tongue. It is described in the section on leucoma and chronic superficial glossitis, and need not be given here in detail. Furrows of the kind first described in the preceding section may be due to syphilis, and are, perhaps, more often due to syphilis than to any simple cause ; but even when the same appearance of the surface of the affected part is produced, the furrows can rarely be so thoroughly smoothed out, for they have far more frequently been preceded by ulceration, or have been the seat of ulceration at some later period. It seems by no means unlikely that the disease which has been alluded to under the name " dissecting glossitis " may sometimes own a syphilitic origin ; but it is held to be quite unconnected with syphilis by Demarquay. Under the term sulcated tongue, Hutchinson describes an appearance of the tongue which he compares to brain coral, convolutions like the brain, " cerebriform," alternatively " fern- leaf pattern " tongue. In one case, a man, aged forty-six, dis- tinctly remembered having it when aged twelve. Another instance was in a patient aged forty-four, and in both instances there was a gouty history, but no evidence of syphilis. HERPES OF TOM; I' I-:. 109 In all cases of furrows upon the tongue which are liable to become inflamed, it is very important to keep the furrows clean and free from germs by painting a mer- curial solution, perchloride, biniodide, or bicyanide, 1 in 1,000, upon the tongue night and morning, afterwards rinsing out the mouth with water. 4. Glossodynia Exfoliativa. This form of superficial glossitis connects itself with neur- algia of the tongue (Chap. XII.), the only difference being the actual evidence of inflammation, and, in addition, the separation in a more or less marked degree of the corneous layers of the epidermis. The name was used by Kaposi, who wrote at length on the subject. It generally occurs in poorly nourished, amemic, and neurotic women, who complain of burning pain set up by mastication and by continuous speaking, the pain being sometimes termed unendurable. Bright red spots and streaks or patches are seen on the separation of the epidermis, through which the papilke appear enlarged owing to the infiltration by inflammatory cells. The affection is, on the whole, chronic ; quiescent intervals alternate with exacerbations, and the disease may go on for years. There is great difficulty in eating, owing to the pain. Treatment is not a success, the application of increasing strengths of nitrate of silver gives relief by forming a protecting pellicle. The actual cautery has been recommended with the object of destroying the nerve ends. 5. Herpes of the Tongue. A group of affections characterised by the formation of herpetic vesicles surrounded by a zone of inflammation. The vesicles very speedily rupture or become pustular, after which they may dry up, or the epidermis may peel oft', leaving an ulcer. The term " hydroa " is also used. The term " aphthous " is largely employed, but, as mentioned before, this term should be applied only as equivalent to thrush. The term "herpes" is justified by the similarity of the affection to herpes of the skin, viz. the rapid formation of vesicles upon an inflamed base. The vesicles form in the layers of the epidermis by the exudation of lymph, 110 DISEASES OF THE TONGUE. which partly collects in them, partly infiltrates the covering epidermis. The vesicles burst at a very early stage, and the collapsed covering forms a pellicle which can be detached, exposing a superficial ulcer. This pellicle is composed of the corneous layers of the epidermis, thickened by infiltration with the fibrinous exudation, The pellicle, therefore, differs from a diphtheritic or other membrane, Avhich consists practically entirely of fibrinous material with only a relatively small number of epithelial cells, and it differs from the pultaceous layers of thrush, in which, if uncom- plicated, there is no fibrinous exudation. The marked tendency of all forms of herpes is to recur again and again, with intervals in which the tongue becomes normal. There are many clinical types of herpes. One is the nervous type. A crop of vesicles forms on the margin of the tongue, with sharp pain and such great tenderness that the tongue cannot be moved, and the patient is afraid to take food. It may be accompanied by herpetic eruptions on the face, lips, and other parts of the body. It is closely connected with the neurotic form of hemiglossitis already described, except that there is no swelling of the substance of the tongue. It is par- ticularly common in women. Michelson described several cases in which the woman had a febrile attack with burning pains in the tongue, white papules formed like peas, the contents of which soon became greenish pus. The epidermis was pushed off' and jagged ulcers left, which healed in about three weeks without special treatment, but tended to recur. Another form of herpes is provoked by dyspepsia, especially when that is associated with in- temperance. The patient whose tongue is illustrated (Plate I., Fig. 1) was a man between forty and fifty, hard- faced, bloated, and with all the appearance of habitual intemperance. His tongue was thickly coated toAvards its tip. There the mucous and sub-mucous structures were a little swollen, a little indurated. The surface was redder than the rest of the mucous membrane, but mottled with bluish - white, slightly uneven, and here and there raised into a tiny vesicle or pustule. All the diseased region ///:/,'/'/> WITH SKIN AFFECTIONS. Ill was sore and tender to the touch. The patient had suffered thus for several days, and in a few days more he was well. Herpes of the tongue also appears in patients who have been exposed to bad weather. In one case, described by Hall, a man, aged twenty-seven, after exposure was seized with a shivering attack ; an erysipelatous blush appeared on the face, and numerous vesicles formed on the lips, tongue, pharynx, arms, and hands. In the exceptionally severe cases of herpes, where the vesicles are so large as to be termed bullse or pemphigus, similar bullie may appear on the skin, especially in connec- tion with the genital apparatus, and the tendency to re- currence is very marked. Rosenthal would class these affections, including urticaria and herpes, under the term erythema exudativum multiforme, the pemphigus then being known as erythema bullosum. Willan quotes a case reported by Dickson in 1787, in which a delicate woman, exhausted by nursing her husband through an attack of low fever, was herself affected with O symptoms of fever and with a sore throat. On the fourth day of the fever there were large vesications on the tongue and insides of the cheeks filled with yellowish serum. This was followed by a general outbreak of pemphigus over the surface of the body. A certain number of cases of herpes of the tongue, es- pecially the persistently recurring type, occur in men who have had syphilis, there being at the same time a tendency to recurring crops of similar vesicles on the glans and fore- skin. These recurring attacks are most easily excited, especi- ally by irregularities in smoking and drinking. They are often regarded as a directly syphilitic lesion, and are occa- sionally quickly relieved by anti-syphilitic remedies. But this is rarely the case, and sometimes the anti-syphilitic remedies appear to do more harm than good. Perhaps Fournier's parasyphilitic theory affords an explanation. The syphilis has disturbed the patient's general health and nervous system, and the recurring herpes is one of the results. The tongue may take part in general pustular eruptions. Pustules may occur on it in the course of small- 1U2 DISEASES OF THE TONGUE. pox. A general pustular eruption, " impetigo," such as occurs in neglected and exhausted children, is connected in origin with the staphylococcus pyogenes, and is spread by inoculation from previous pustules. Thus, pustules about the lips may serve to transfer the infection to the mouth and tongue as well as to the skin. The* treatment of the more obstinate forms of herpes of the tongue is very disappointing. Attention to diet, the avoidance of stimulants, and careful cleansing of the mouth will meet the lighter cases. In other cases a dose of blue pill will do wonders. And, again, in some nervous patients, a grain of opium in the solid form will at once relieve the attack. But in the recurrent cases it is exceed- ingly difficult to know what treatment to pursue. Arsenic, which has been strongly recommended by Hutchinson, has not seemed to us to prevent the recurrence of the disease, nor has any drug appeared to exercise a decided influence on it. Close observation of some of the very acute recur- rent cases led us to form the opinion that the disease, in spite of the absence of the proof of micro-organismal origin, may be contagious from one part of the tongue to other parts. Acting on this assumption, antiseptic applications have been ordered in several cases, and the experiment has thus far been more successful than any other treatment. A young lady, about seventeen years of age, suffering from one of a series of very sharp attacks of herpes, chiefly of the tongue, but not strictly limited to it, had tried various applications without relief. She was ordered to dry the tongue carefully with clean soft rag, and then to rub in all over the affected area a mixture containing carbolic acid, spirits of chloroform, tincture of myrrh, and eau-de-cologne. This she did diligently and frequently, in spite of the pain of the first applications ; and with such success that the eruption speedily disappeared, and was not followed by recur- rence. A delicate, very anaemic lady, about fifty years of age, suffered the most cruel tortures from repeated violent attacks of herpes of the tongue, the palate, and the insides of the cheeks and lower lip. She had been long under treatment, but without relief, and was very reduced in health, not only by the pain, but by the impossibility of taking PLATE IV. Fig. 1, Mucous patch, deeply grooved and ulcerated. The yellower tongue- like portion towards the dor sum shows the manner and area over which it had extended in the course of a week. Fig. 2. Gummatous ulcer of border in a man, aged 25. The slough has not heen completely removed. Fig. 3. Large cleft or fissure-like cavity produced by the breaking of gummata in the tongue of a man, aged 39 years. The cavity is repre- sented as it appeared when its sides were separated by the fingers. TREATMENT OF HERPES. 113 sufficient and fit food during the attacks. The same appli- cation of carbolic acid was ordered for her, with similar directions for its application, but she found it absolutely impossible to bear it. She was then ordered an ointment consisting of 4 or 5 grains of cocaine, 10 grains of boracic acid, 2 drachms of vaseline, and 6 drachms of lanolin. The tongue was dried before each application, and the ointment was then applied. A portion of it, like a little piece of butter, was placed upon the tongue, and was thoroughly rubbed in by pressing the tongue against the palate and inside of the cheeks and gums. This was carried out many times during the twenty-four hours, with such success that the attacks were speedily diminished in severity, and finally, at the end of several weeks, were completely cured. She had a slight relapse some months later, but a repetition of the treatment again speedily relieved her. Herpetic ulcers of the tongue, formerly termed " aphthous," which are seen especially in children, are described in Chapter IX. 114 CHAPTER VIII. CHRONIC SUPERFICIAL GLOSSITIS. Leukokeratosis, Leukoplakia, or Leucoma of the Tongue ; Nomenclature ; Patho- logical Anatomy ; Clinical Description : (a) Smoker's Patch ; (b) Leukokeratosis or Leucoma ; (c) Icthyosis ; (d) Smooth Tongue ; (e) Gouty and Rheumatic Patches ; (/) Patches on the Tongue with Skin Affections, Eczema, Psoriasis, Lichen, Lupus Hyperkeratosis Linguae, Hairy Black Tongue, or Xigrities. THE subjects dealt with in this chapter have also had a great number of names applied to them, of which some explanation must be given. The important characteristic of all is a disposition to change of form and to over- growth of the epidermis, which has become known under the term keratosis. It is this change in the epidermis upon which the chief interest centres, because, by further modifications of the process, the important sequela, epi- thelioma, ensues. This keratosis is distinguished into two forms : (1) An increase of the stratified epithelial corneous layers, with a tendency towards the disappearance of the normal papillae, so that white, smooth patches are formed by various thicknesses of the corneous layers of the epidermis. This is the important process which, with manifestations of in- duration and ulccration, precedes the development of epi- thelioma. (2) An overgrowth of the filiform papillse, hyperkeratosis, so as to form hair-like filaments, consisting of epithelial scales, which generally become black, " the hairy or black tongue." This form is of great interest, but of little clinical importance, is temporary, and does not lead to cancer. 1. Leukokeratosis, Leukoplakia, or Leucoma. The patches formed by chronic superficial glossitis are objectively white, and, anatomically, the process is one of keratosis or cornification. Hence, of all the names for this LEUKOKERATOSIS. 115 disorder, leukokeratosis has the most significance. Leuconia, suggested by Hutchinson, though perhaps not scientifically so correct, has the advantage of being a short word, and was used in the last edition of this work. Leukoplakia, proposed by Schwimmer, and leucoplasia are in common use, signifying white patches, but do not carry so full a meaning as leukokeratosis. Psoriasis is also a word in very common use, but there is room for confusion, as there are three senses in which psoriasis of the tongue may be employ* < 1 : (a) The strict sense, in which the affection of the tongue is present with simple psoriasis of the skin ; this is a rare affection, but it does occur ; (6) so-called syphilitic psoriasis, or scaly syphilide, in which there is a simultaneous affection of the tongue and of the skin ; (c) the affection of the tongue, quite distinct, on the one hand, from simple psoriasis, on the other, having no connection with syphilis, caused, e.g. by smoking. Icthyosis is the name given to the affection 1>\ Hulke ; it is especially applicable to advanced stages of the affection, in which there are hard and warty areas. Tylosis is the name for callosity. It is now rarely applied to the tongue. Filmy patches or opaline plaques are suitable clinical names for some of the less marked types. Boiled white of egg was the appearance to which Lawrence, in 1 862, compared a patch on the tongue, which he first shaved off and upon its recurrence excised. He found that the material removed consisted only of thickened epidermis, and was not cancer. Hulke, in 1861, gave a microscopical description of the epithelial changes which produce the patch, and, later, showed the tendency of the disease to pass on to epithelioma. Pathological Anatomy. Sangster has given a good de- scription, with drawings of the general changes, and Butlin has particularly described the anatomy of the smooth variety of chronic superficial glossitis. Recently more minute changes in the epithelial cells have been studied by Leloir, especially in relation to the epitheliomatous change. In the common forms the papilla? disappear, leaving a smooth patch, covered only with a thin layer of corneous epithelium, the layer being often thinner than the normal epithelium. The pro- cesses going on are a proliferation of the cells of the 116 DISEASES OF THE TONGUE. Malpighian layer, with a collection of leucocytes immediately below the epithelium, a gradual shrinkage and disappearance of the papillae, with the formation of some scar-like tissue immediately beneath the epidermis. At first sight, one might suppose oneself looking at a section from the mucous membrane on the under surface of the tongue, where there are normally no papillae. Yet this section from the dorsum differs from the normal mucous membrane of the under surface by having scar-like tissue immediately beneath the epidermis, and there are fine granular changes in the epithelial cells which are not seen under normal conditions. In other words, the patch appears to be scar-tissue covered by a thin layer of epidermis. The less common form is concerned, like the other, with a disappearance of the papillae, the collection of leucocytes below the epidermis, and the formation of scar- tissue there. (Fig. 8.) But, in addition, there is an increased thickness of the corneous layers of the epidermis, until, in this special respect, the section may come to have an appearance re- sembling a section of the skin of the palm. The amount of leucocytes and of new-formed fibrous tissue beneath the epidermis varies with the amount of inflamma- tion which has taken place. In this respect, an actively inflamed patch will differ from one which has existed quietly for years. Recently much attention has been paid to minute changes taking place chiefly in the layers of cells immediately above the Malpighian layer. The cells of the granular layers become vacuolated and show granules of eleidine. This is a change similar to that which is seen so abundantly in the cells of epithelioma. It is looked upon as a degenerative process, a dekeratinisation, as the stage immediately pre- ceding the time when the epithelial cells, ceasing to grow upwards, will, as it were, turn about and form downgrowths of epithelium, which mark the beginning of cancer. (a) Smoker's Patch. Under this name is understood an altered condition of the epithelium of the dorsum of the tongue, due to smoking. In the most typical instances it appears about the middle of the front part of the dorsum, but on one side of the middle line, just where the end of the SMOKER'S PATCH. 117 tobacco-pipe rests, or where the stream of smoke from the pipe or cigar impinges on the surface of the tongue. At this point there is noticed a patch or slightly raised area, generally of oval shape, and at first of very small size, not more than Fig. 8. CHRONIC SUPERFICIAL GLOSSITIS. Photographed from a section through a patch (see PI. V., Fig. 1) on the excised portion of the tongue of a woman aged 37, who had been seen by de Havilland Hall and Butlin four years before. Epithelioma commenced at some distance from the place from which the above section was taken, and the diseased portion was excised by Speni'er. The patient is living twelve years after the operation with the rest of the tor.gue sound. She had not smoked, nor was there evidence of syhhilis. She had suffered from dyspep'sia, was fond of spices and hot drinks, and shortly after the excision had a bad attack of gastric ulceration with hsematemesis. The photograph shows below the epithelium scar-tissue with collections of leucocytes, the papilla^ are irregular, the epidermis is much increased in thickness, especially the corneous layers, the lower layers of the latter appear as a light band owing to the cells being vacuolated and tilled with eleidine granules. The cells above the Malpighian layer show the same changes to a less extent. Although the papillse ars irregular, there is in the specimen no definite downgrowth of epithelium. a quarter to half an inch long, and about half as broad as it is long. The surface of the patch may exhibit a perfectly smooth red or livid aspect, not ulcerated, or even excoriated, but looking merely as if the papillae had been removed. It is not obviously swollen, but rather appears depressed in the midst of the furred papillre by which it is everywhere 118 DISEASES OF THE TOXdl'K. surrounded. By-and-by it becomes covered with a layer of yellowish-white or yellowish-brown material in the form of a thin crust, which grows thicker, until at length it peels off or is removed, and the red smooth spot is again exposed. In other cases, instead of a red or crusted patch, there appears a bluish-white or pearly patch, without any sur- rounding redness or sign of inflammation. It is usually perfectly smooth, and quite as sharply defined as the red patch, and is very evident, unless the dorsum of the tongue in the immediate neighbourhood is covered with fur of the same tint. Even then the smoothness and pearly aspect of the patch distinguish it from the natural surface of the tongue. The affected area is not always limited to the region of the dorsuin near the middle line, but has a tendency to spread very slowly over the surface of the dorsum, until the whole of the upper surface in front of the circumvallate papillae may be affected. The inside of the cheeks is liable to become similarly diseased, particularly along the line where the teeth meet, a circumstance which may be ascribed partly to the fact that the smoke reaches this part of the inside of the cheeks more directly than any other part, and that this line is more exposed to injury from the teeth than the higher and lower lines. The mucous membrane of the cheeks is so readily affected that it is often the seat of disease, when only a single small patch is apparent on the surface of the tongue. When the entire surface or large areas of the dorsum are affected, the disease ceases to be called " smoker's patch ; " it is known by the names psoriasis, leucoma, leukoplakia, etc. The fully-developed disease will be considered in the next section, and only the limited affection to which the name " smoker's patch " is given will be discussed here. The smoker's patch is not at all painful or tender, unless it has been irritated and made raw, and its presence is often only accidentally discovered. If the end of a pipe, especially if the pipe is made of clay, is allowed constantly to rest on it, it then not uncommonly is a little tender, and the slight tenderness draws the attention of the smoker to it. The patch may remain in one of* the conditions described TREATMENT OF SMOKER'S PATCH. 119 during very many months or years : indeed, we believe the bluish patch may remain, with little alteration, the same during man}- years, and the crusts may form on the red patch and peel off for years; but it is much more usual for the disease to spread over the surface of the tongue if the irritation is continued. On the other hand, the red patches n iav be quite restored to their normal condition, and pos- sibly even that the bluish-white patches may undergo resolution, although that is far less probable. Smoker's patch is apparently a patch of inflamed mucous membrane of the dorsum, produced by the irritation of the column of smoke impinging on it, or if produced by the contact of the stem of a tobacco-pipe, yet certainly main- tained in great part by the irritation of the tobacco. The inflammation is so chronic, and the changes are so slow and, one may almost say, so trivial at first, and for a long time, that they excite no annoyance, and are not noticed until the condition has existed a considerable time. The consequence is that the disease, trivial as it is at first, has gained a tolerably firm footing, and slight thickening of the deeper layers of the epithelium and of the superficial layers of the cutis of the mucous membrane, not perceptible to touch, are already present when it is discovered. Even if the use of tobacco is abjured, or if care is taken to protect the affected spot from the impact of the smoke or the contact of the pipe-stem, the diseased area is not always resolved. It may remain with little alteration, or may extend over the surface of the tongue. The treatment of the less extensive patches and of those in which the disease appears only to have been present for a little while (in which, for example, the area is still merely redder than natural, and smooth) consists in taking pre- cautions to prevent the pipe-stem or column of smoke from directly touching the aflected spot ; it is not necessary to forbid smoking, but if the patient is an inveterate smoker, the amount of tobacco and the form in which it is smoked may be advantageously altered. He should be restricted to fewer cigars or pipes, and the pipe he smokes should not be very short, and its stem, particularly that part of it which is held within the mouth, should be very smooth, and made 120 DISEASES OF THE TONGUE. of the least irritating material possible. He should certainly hold his pipe or cigar in the side of the mouth opposite to that on which is the affected area. The patch may be painted occasionally with a solution of chromic acid, about five or ten grains to the ounce, or with a weak solution of tannic acid or alum, applied with a soft camel-hair brush. If the disease is more extensive and appears to be ex- tending on the tongue, or is present at several points on the tongue, and perhaps upon the inside of the cheeks as well, a more decided plan of treatment must be adopted. The patient must be urged to forbear smoking, not only on account of the disease actually present, but of the pro- bability that, if the irritation is not removed, it will extend widely and become a serious mischief, the precursor, possibly, of much more grave trouble. If the patient refuses to obey the order not to smoke, he must at least be considerably restricted in the use of tobacco. In addition, every pre- caution must be taken, by careful attention to diet, to prevent the surface of the tongue from being irritated by too sweet, too sharp, or sour, or strong foods and drinks. Spirit, unless largely diluted, is decidedly prejudicial, and strong wines, like sherry and port, are injurious. The tongue should be painted three or four times in the day with a solution of chromic acid or with borax and honey, or with a weak astringent. Chlorate of potash lozenges or tablets are used. The bowels must be gently opened once every day, and if the general health is not good, and the patient comes of a gouty or rheumatic family, or if he has had syphilis, the constitutional treatment must be directed to the bettering of his condition. It may seem almost ridiculous to enforce or recommend so many rules for the relief of so trivial an affection, but there is ample reason for the exercise of every possible care in the early stages of the disease. If it is curable, it is only in the earlier stages ; and if it extends so as to cover a large area of O ' O the tongue, it becomes a source of serious annoyance to the patient, which, from the difficulty or impossibility of curing it, lasts his whole life through ; and it may, if neglected, be a strong predisposing cause of cancer. Patients who are not disposed to deny themselves the VARIETIES OF SMKI-:irS PATCH. 121 smallest luxury when the disease is in an early stage, are often forced in later life to live very careful lives, for- swearing tobacco and stimulants, besides using every care in the kind and condition of the food they take. To avoid so much distress in later life, it is worth while to use self-denial for weeks or months when the disease is just commencing. The two following cases are admirable illustrations of two varieties of smoker's patch, one from the practice of Sir James Paget, who very kindly permitted us to use his manuscript notes of it. r,/.> 7 /,// u IK ling parts. On the under aspect of the tongue, where the patches are as little as possible disturbed, either by the teeth or by the passage over them of food, they not infrequently appear as excellent examples of condylomata, warty, cauliflower- like (Plate VI., Fig. 3). The surface of each growth is white, and, as a rule, a more dead white than that of the patches on the dorsum. The base of each is often slightly con- stricted, but they are very rarely much elevated, for the conditions under which they grow and the soft materials of which they are composed are not favourable to large development. If they reached a greater height than a (jimrter of an inch, they would speedily be rubbed down and flattened out by the surrounding gums and teeth. These little condylomata, like the mucous patches on the dorsum, are absolutely free from any signs of inflammation. On the tip and borders the characters of mucous patches are often so modified that the appearances they present are very different from those which have been described. The patch is still raised and still white, and often roughly retains its oval shape, but the borders are frequently sinuous or deeply notched, and immediately beyond is a bright red areola, extending for about an eighth of an inch into the surrounding natural red, in which it gradually fades (Plate IV., Fig. 1). The surface of the patch, instead of being smooth or warty, is ulcerated, or deeply grooved and hollowed out, or marked by vertical lines of red and white alternately ; and all this is due to the pressure or rubbing ot the teeth or stumps of teeth. The extent to which a patch on the border of the tongue may be altered depends, of course, on the thick- ness or height of the patch, on the condition of the teeth, and on the condition of the tongue, which may be generally larger than it ought to be, so that the patch is pressed outwards against the teeth. The ulceration may be merely superficial, and may affect only a part of the surface of the patch : or it may be so deep and so extensive that it not only almost wholly destroys the patch, but eats deeply into the substance of the tongue as well. On the other x 194 DISEASES OF THE TONGl'l-:. hand, I have seen patches on the borders which, on account of their very slight elevation, and of the small size of the tongue and smoothness of the teeth, were nearly as well preserved as the patches far back upon the dorsurn. The first appearance of the mucous patch is usually in the form of a very small and slightly raised white-grey spot, perhaps not larger than a small split-pea; but it quickly enlarges, without any sign of inflammation, and, unless it be ulcerated or injured, is probably for a long time unnoticed by the patient. Several patches may coalesce, and in this manner some of the large and most irregularly-shaped patches are formed. The entire patch may continue to enlarge in all its diameters so as to preserve the original shape of that which first appeared ; or it may put forth tongue-like pro- jections, which spread over the adjacent surface of the tongue, and are recognised by their yellower colour and less thickness when compared with the original patch. If they are left untreated, mucous patches may remain for a long time very little altered, or they may slowly extend until a large part of the surface of the tongue is covered by them, or they may undergo some of the changes which have been described, may lose their white coating, or may ulcerate on account of the irritation they are subjected to. They may heal, too, spontaneously, for many persons pass through the entire period of secondary syphilis without treatment, and all the symptoms disappear. The worst cases, however, come under treatment, and we can certainly say that we have watched mucous patches, especially the condyloinata on the under aspect of the tongue, for many months, and have noticed no alteration in them, although afterwards an application of chromic acid has caused them to disappear entirely in the course of a few days. It must be borne constantly in mind that the secretion which comes from these mucous patches and the discharge which proceeds from the ulcers which form in them is contagious. A person, therefore, who is suffering from mucous patches and other secondary affections of the in- terior of the mouth, especially from secondary sores on the lips and at the corners of the mouth, is dangerous to those with whom he lives and with whom he works. He should CONTAGION FROM MUCOUS PATCHES. 195 be warned against kissing when his mouth is sore, against allowing other persons to use the same glass and pipe as he uses, the same fork, and the same tools, if they are used within the inouth. Mr. Hulke mentioned a boy under his care who had contracted syphilis by using his neighbour's l>low-pipe in the shop in which they were em- ployed. So, also, we have seen a young woman with a primary sore upon her nipple, which she said had been produced by a child which she had taken to bed with her for several nights seizing her nipple in the night and sucking it. The child was brought in the following week, and was found to be suffering from syphilis, with mucous patches on the tongue and at the corners of the mouth. Such accidents cannot be too carefully guarded against ; both the patient and the patient's friends must be warned of. the danger, even at the risk of exposing the character of the disease from which the patient suffers. This, indeed, is seldom necessary ; it suffices usually to state decidedly that the disease is contagious, and to point out the manner in which it may be contracted. With regard to the frequency of mucous patches on the tongue, they are not nearly so common there as about the anus and the vulva. Bumstead and Taylor, quoting from the statistical tables of Bassereau, note that in one hundred and thirty men mucous patches were found around the anus 110 times, upon the tonsils 100 times, and upon the tongue only 18 times. Further, they refer to the statistics of Davasse and Deville, who examined one hundred and eighty- six women, with the result of finding mucous patches upon the vulva 174 times, about the anus 59 times, on the tonsils 19 times, and upon the tongue only 6 times. The much larger proportion of men suffering from mucous patches on the tongue has led to the conclusion that probably a determining factor, as well as the generalised syphilis, is active in producing mucous patches on the tongue. This may be found, as Bumstead and Taylor suggest, in the use of tobacco by men. Chewing and smoking are liable to irritate the surface of the tongue, and the slight irritation or congestion determines the formation of a mucous patch. This, however, would scarcely account for the frequency 196 DISEASES OF THE TONGUE. with which the patches are found on the borders of the tongue; it is probable that the irritation of the teeth pro- duces quite as considerable an effect as the irritation of tobacco. Certainly we have more than once seen mucous patches on the border of the tongue directly opposite a rough tooth or stump, the only rough or carious tooth on either side. In the large majority of cases the diagnosis of mucous patches is easy. The patches themselves are very charac- teristic, and the accompanying signs of syphilis render it impossible to err. But occasionally they may be mistaken for leucomata, or aphthae, or wandering rash, or even warty growths: The diagnosis from leucoma depends partly on the difference in the colour of the patches, which are not pearly, like leucomatous patches, but greyish-white, as if they had been painted over with a nitrate of silver stick. Mucous patches occur much more often on the borders, leucoma patches on the dorsum of the tongue; mucous patches are much more often deeply ulcerated than leucoma patches. Leucomas, when thick and white and raised, and, therefore, most likely to be taken for mucous patches, are, as a rule, much harder and drier than mucous patches. Leucoma usually runs a very slow course, mucous patches a comparatively quick course. But the presence of associated signs of syphilis in the large majority of instances makes the diagnosis perfectly clear. In aphthae and in mucous patches the patches are white, but the white patches of aphtha belong almost exclusively to children or to adults who are suffering from very severe illness, while the white patches of syphilis occur almost exclusively in adults, and, for the most part, in adults who are in good, or, at least, not in bad health. In doubtful cases a microscopical examination will prove the nature of the disease. And, once again, the associated signs of syphilis are rarely absent. The diagnosis from wandering rash has been described in Chapter VII. (1) at p. 100. The diagnosis from that very rare condition, diphtheria of the tongue, must depend on the swelling of the base of the tongue, the diphtheritic patch, the general fever, and on the presence of associated signs of diphtheria in the neighbouring parts as well as the finding of the bacilli. In CHROMIC ACID TO MUCOUS PATCHES. 197 the case of diphtheritic inflammation, and the formation of membrane over a wound, the history of the wound and the general illness of the patient tell the character of the (lisi-Msi-. Lastly, it may sometimes happen that warts or warty growths are mistaken for the warty syphilitic tumours. True warts are more common on the dorsum of the tongue, are usually of very slow growth, and are often decidedly of papillary origin. But the diagnosis is rendered easy by the presence of associated signs of syphilis, and by the result of treatment, which is speedily effectual in re- moving syphilitic warty growths, but is almost useless against actual tumours. The treatment of mucous patches was at one time and, indeed, until quite lately regarded as very unsatisfactory, not because the patches could not be cured, or because they led to deep ulcers or to serious mischief, but because they remained so very long uncured. Yet the patients were treated with mercury in sufficient doses, and, being anxious to be rid of the trouble in the mouth, appeared to have taken the medicine regularly. Many local applications were employed without avail, until it occurred to Butlin to try the effect of a solution of chromic acid on them. The result was magical, for the patches and warty growths, which had remained unmoved during many months of treatment, now disappeared in the course of a few days. Since that time we have used a ten-grain solution of chromic acid largely in the treatment of secondary syphilitic affections of the interior of the mouth, and especially for the relief of mucous patches, and almost invariably with a good result. A few cases have resisted the effect of the acid, and it has then been found necessary to remove some source of irritation ; a carious tooth, for example. The patches appear to melt away under the influence of the acid. We have never, indeed, used the chromic acid without, at the same time, treating the patient internally with mercury in the form which seemed most suitable to his individual case, so that we cannot say whether the chromic acid would be equally effectual if used alone. In out-patient practice the only objection to the use of chromic acid is that it relieves the patients too quickly of 198 DISEASES OF THE TONGUE. the annoyance which the mucous patches cause them, and they are, therefore, unwilling to attend sufficiently long to be thoroughly treated for their constitutional syphilis. This objection, which we should be disposed to regard as trivial had we not often found it to be the case, is, however, more than counterbalanced by the advantage to the community of removing as speedily as possible a source of syphilitic contagion. It is not needful to enter into the constitutional treat- ment of syphilitic patches ; it differs in no respect from that which is adopted for the cure of constitutional syphilis generally. (b) Tertiary Syphilitic Plaques and Scierosing Glo**if!*. The affection we are about to describe under this name is scarcely mentioned either in works on syphilis or on the tongue. It is, however, carefully described by Fournier, and the account of it which he has given deserves to be studied. We have only seen a few instances of it, and yet it must be more common than the small number of cases we have seen, and the absence of descriptions, would lead us to believe. For the tertiary plaques are said by Fournier to precede, and be the cause of, the deep fissures and furrows which one sees in old disfigured tongues, where the surface of the tongue has been absolutely ploughed up by past syphilis. We will describe two cases, of which we have sketches by us at the present moment, and which may be taken as corresponding to the deeper sclerosing glossitis of Fournier. The first is the case of a man, fifty-six years old, who was under care in the out-patient room at St. Bartholomew's Hospital in February of 1882. He had suffered from syphilis many years previously, and had been accustomed to smoke and drink a good deal, although lately his tongue had been so tender that he had been compelled to diminish largely the amount of spirit and tobacco. As far as could be ascertained, he had suffered from superficial glossitis for many years, but when he came to the hospital he was quite ill, on account of an acute attack which had super- vened upon the old inflammation, and which had produced sloughing of the surface at three separate points : in neither TI-:I;TIARY SYPHILITIC PLAQUES. 199 of them deep destruction, but in all sufficiently deep to leave shallow ulcers and to give the man great pain, especially when he took food into his mouth. But the feature of the disease was the presence of a singular plaque, or tuber- cular mass, in the middle of the dorsum. It was of oval shape, and measured about an inch and one-third by one inch, and in its central parts, which were the most elevated, it stood about one-eighth of an inch above the level of the surrounding dorsum. It had the appearance of having been formed by the meeting of half-a-dozen flattened tubers, one in the centre and five around, for there were deep furrows or clefts, breaking up its surface into several different segments, but of different sizes. Each segment was smooth, dull red, flattened on the summit, but rounded where it met the adjoining segments. The whole of the plaque was firm and elastic, and quite insensitive, except where it was affected by the acute inflammation which had seized the fore part of the tongue. And only at this inflamed part was there any sign of ulceration which was not deeper than the superficial ulceration of the fore part of the tongue. The patient was not sure how long this plaque had existed, for it had given him no trouble, and he would not have applied at the hospital on account of it had he not been driven there by the sharp attack of inflammation which caused him so much distress. As soon as he was relieved of this, his visits ceased. The second case is more interesting for several reasons, for the progress of the disease was watched from first to last, and the objection which may be made against the first case, that the diagnosis was not absolutely certain (of syphilis), cannot be maintained in this. The patient, who was thirty years of age, was also under care in the out- patient department of St. Bartholomew's Hospital for a very long time on account of extremely severe tertiary syphilis. He first came in February, 18cSl, when he was suffering from several smooth plaques on the left half and border of the tongue. The plaques were three in number, of irregularly rounded shape, ver}- smooth, raised to the extent of half a line to a line, and rather higher in the centre than at the borders, and redder than the surrounding 200 DISEASES OF THE TONGUE. parts : even where there was 110 fur, they were well defined. At first they were thought to be ordinary gummata, but, on closely examining them, it was found that, although they measured from a quarter to three-quarters of an inch across, they had scarcely any depth ; they were, however, firm and almost parchment-like. The primary attack of syphilis had been about four or five years previously, and the secondary symptoms had lasted for rather more than a year. Since that time he had had ulceration of the scalp and skin of the forehead, and while he was under care ulcers broke out in various parts of his body as well as on his tongue. The patches on his tongue had been noticed for about two months past : first one of them had appeared, then the other two, and they had slowly increased in size. It was not certain whether they were superficial gummata or whether they corresponded with the tertiary tubercular syphilide which one sees not uncommonly on the face and other parts of the surface of the body. In either case the treatment was the same, so he was put on iodide of potassium, and the plaques were painted with bicyanide of mercury. Under this treatment they soon improved, but, owing to his irregular attendance at the hospital, and consequently to his being without medicine for a week or more at a time, the largest of them grew larger still, and without becoming more promi- nent, broke down into ulcers, not absolutely superficial, yet not deeper than the eighth of an inch. Under renewed and more regular treatment they soon healed, leaving super- ficial, yet clearly discernible, scars. The other plaques dis- appeared without ulcerating. In November of the same year he returned to the hospital with a fresh outbreak of syphilis of the scalp and neck, and a singular plaque in the middle of his tongue, of which Mr. Godart made a sketch. It was about an inch long, and made up of two separate oval plaques, which afterwards coalesced, and increasing considerably in size, formed a single plaque, measuring two inches long by three-quarters of an inch across. It rose almost abruptly from the dorsum, and in the centre reached a height of about one-eighth of an inch, but was a little less elevated at the sides. It was perfectly smooth and of a deep red colour, but with a decided purple tint. Down SCLSR08ING GLOSSIT1-. 201 the centre ran the groove formed by the meeting of the two original plaques. The whole plaque was glazed and shiny, and was at no point broken or even slightly cracked (Plate VII., Fig. 1). It felt very firm, but the firmness did not extend far into the substance of the tongue. The rest of the dorsum was healthy, exdept for the trivial scars on the left half, and two lumps, gummatous, on the right border. There were no signs of inflammation about the central plaque or in connection with the guinmata. Five grains of iodide of potassium and a drachm of the liquor hydrargyri bichloridi were administered three times a day, and the surface of the tongue was ordered to be painted several times daily with a ten-grain solution of chromic acid : but at the end of a couple of months there was no improvement. He was then put on ten grains of iodide of potassium and half a drachm of the bichloride, with the result that, although the chromic acid was left oft', and no external application was employed, the plaque quickly diminished in size, and at the end of another month had melted away. There was never at any time ulceration ; the plaque disappeared, without leaving any trace of its existence. Of course one cannot say what course it might have pursued had it been left untreated. Fournier's account of the sclerosing glossitis of tertiary syphilis is that it produces cellular hyperplasia, which in- filtrates the tissues of the tongue. In process of time these patches or areas of cellular hyperplasia multiply, then become organised, condensed, and end by forming a fibro- plastic, fibroid frame. With the organisation and conden- sation of the frame there occurs contraction, so that the natural tissues of the tongue are strangled and atrophied, and in this manner cirrhoses, or more properly scleroses, are produced. He divides the lesions into superficial or cortical, and deep or parenchyrnatous. The superficial sclerosing glossitis takes the form of superficial indurations, which are developed in the derma of the mucous membrane. They are extensive and lamelli- form ; either isolated plaques of variable extent and form, from the size of a threepenny-piece to that of a haricot 202 DISEASES OF THE TONGUE. bean, usually rounded or oval, easily perceptible to touch, like discs of parchment, of deeper cherry red than the normal surface of the tongue, uniform and smooth, without papillae, often not at all elevated above the surrounding surface. Or they form continuous plaques, covering two to four square half-inches, or even more, and presenting similar characters to the isolated plaques. Both the isolated and the confluent plaques are prone to break down with the production of fissures, chaps, chinks, erosions, and ulcers. The sore places are not usually painful. The disease is very chronic, and leaves behind rnilk-white patches. The deep or parenchymatous sclerosing inflammations are generally both deep and superficial, but they may be limited to the deeper parts. They are characterised by swelling on the dorsal aspect of the tongue, which is later followed by atrophy. The surface of the dorsum is mammilated and lobulated, and the lobulation is like that of the surface of the liver in cirrhosis. It is so frequent a symptom of syphilitic sclerosis that it is almost pathognomonic of syphilis. The central parts of the dorsum are the most frequently affected,, but the borders may also be attacked, in which case the dental arcade is marvellously reproduced upon the tongue. Another character is deep induration of the affected parts, not unlike that of cancer. Lastly, there is morbid redness, of a vinous hue, of the mucous membrane, which is smooth and without papilla?. Erosion and ulceration may occur from various causes, and are especially liable to affect the furrows and fissures which result from contraction of the organised tissue. A rare variety of sclerosing glossitis is that in which the disease is generalised, when, with the preceding signs, the entire tongue is enormously swollen and hard, the so-called syphilitic macroglossia. The course of all the sclerosing inflammations of the tongue is essentially chronic ; and if they are left untreated they are prone to break down and ulcerate, but the ulcers are rarely deep or difficult to heal. The lymphatic glands are practically never enlarged in association with them, although it is not impossible that inflamed and ulcerated plaques may produce enlargement of the glands. DIAGNOSIS OF SCLEROSING GLOSSITIS. 203 Fournier gives an elaborate account of the />. between these sclerosing inflammations and various other affections for which they may possibly be mistaken. In this category he places indurated lingual chancre, lingual psoriasis, smoker's patch, and dental glossitis. But it is difficult to understand how any of these diseases can le mistaken for the disease which has been described. Nor do we see how epithelioina of the tongue is so likely to be mistaken as Fournier supposes, unless in those rare cases in which the syphilitic affection is much deeper and more gummatous than usual. The local condition is for the most part quite characteristic, and when there is doubt, there are almost always other signs of syphilis, either of the tongue or of some other parts of the body, which help to solve the question of the nature of the disease. The effect of treatment is, too, speedily useful in determining the syphilitic origin of the plaques At a later period, when the tongue is fissured and furrowed by the contraction of the plaques and trabecula? of syphilitic scar tissue, there is little fear that any other disease will be taken for it. The prognosis, if the disease is extensive, or if it has been untreated or has been imperfectly treated, is bad, for the tongue is generally horribly disfigured by the subsequent contraction. The plaques of sclerosing glossitis are, too, almost always associated with the formation of gummata in the tongue, and these, breaking down, increase the deformity. Hut if the affection is treated early and thoroughly, the result is generally good. In the same way that gummata are completely removed under appropriate treatment, pro- vided the treatment has not been too long deferred, the plaques of sclerosing glossitis apparently may be resolved by treatment. In the treatment of sclerosing inflammations, whether superficial or deep, iodide of potassium plays by far the most important part. It may at first be administered in doses of five to ten grains three times a day; and if a decided effect is not speedily produced, the dose may be increased rapidly to twenty-five or thirty grains. With iodide of potassium, the solution of the bichloride of mercury may be given : and in most cases cod-liver oil and tonics 204 DISEASES OF THE TONGI'h'. are useful, for the patients are usually in defective health. In the stage of the disease in which contraction has taken place little or no benefit is to be expected from anti-syphilitic treatment. The disease has done the worst of which it is capable, and the only result which can be hoped from treat- ment is to palliate symptoms as they arise. In the majority of instances local treatment is not necessary, and, indeed can do no good. But when the plaques are ulcerated and are sore, they may be painted with a solution of chromic acid, or may be rubbed, as Bryant recommends for gum- mata, with a mass of blue pill. When there are deep fissures in which organisms lodge, the patient is much relieved by the thorough painting over the tongue every day of perchloride or bicyanide of mercury, 1 in 1,000, part of the value of which is the destruction of micro-organisms which increase the inflammation. Heath recommends that the mouth should be filled with the solution for five minutes, but this is only suitable for careful patients who would not swallow the fluid. (c) Syphilitic Atrophy. A very different result of syphilis was noted by Yirchow in 1863, and his observations have been recently confirmed by Lewin and Heller, but are not accepted by all authorities. The disease is said to consist in a gradual shrinkage ol the lymphatic gland follicles until they completely disappear from the centre of the base of the tongue behind the lingual V, but some remains of the lymph follicles are always to be found at the sides. The epithelium remains normal, and there is no small-celled infiltration, simply a smooth atrophy, which they believe to be important as showing the con- tinuance of the syphilitic virus. The observations are sup- ported by drawings and microscopic sections. (d} Syphilitic Nodes and Nodules; Gumnt/t ilia are formed almost always on the borders of the tongue, and are due almost as much to the nibbing of the teeth as to the syphilis. One of the conditions most frequently observed is that in which a mucous patch is developed on the border of the tongue, and being pressed on, or rather into, by the teeth against which it projects, ulcerates. The ulcer is linear or stellate, and gradually deepening, owing to the continuance of the pressure which first produced it, becomes by-and-by a deep and foul fissure. Any other swelling of the border of the tongue might lead to similar ulceration and fissuring ; but it is more than probable that the syphilis acts as a powerful predisposing cause. In secondary syphilis, too, it is not uncommon to meet with cases in which, without the development of mucous patches, the margins of the tongue are in many places ulcerated and sometimes deeply fissured, and this condition also is due in great part to the rubbing of the teeth against a tongue which is predisposed to inflame and ulcerate. These sores and fissures are scarcely at all inflamed, and are not angry, like the sores and fissures which are produced in persons out of health, but who are not syphilitic. In spite of the absence of a red areola, and the signs of inflammation, these cracks and fissures are usually very sensitive, and from the constant movement of the tongue, and the continual irritation to which they are subjected, are a source of great annoyance to the patient. The syphilitic fissures are generally easily recognised by the signs to which attention has been directed, the absence of the active symptoms of inflammation, the presence of numerous sores and fissures, and by the frequency with which they are associated with other signs of syphilis, either upon the tongue, cheeks, and lips, or in other parts of the body. The fissures which are formed in mucous patches are still more easy to diagnose ; for although the aspect of the patch is greatly changed by the ulceration, 214 DISEASES OF THE TONGUE. it can be generally discerned for what it is, and is very often accompanied by other tubercles upon the sides or dorsum of the tongue. They will be distinguished from the single tuberculous fissures by the absence of the signs already noted for that lesion. The treatment of these secondary fissures is usually very successful. Unless they are produced by the irritation of very carious and jagged teeth, the removal of the neighbour- ing teeth is not necessary. The internal administration of mercury, and the general constitutional treatment advisable for secondary syphilis, with, above all, the external application with a camel-hair brush of a ten-grain solution of chromic acid, heal them with the greatest rapidity. They cease almost immediately to be so sensitive, and in less than a week are, for the most part, scarred over. As is pointed out in the chapter on ulcers, the internal administration of anti- syphilitic remedies may not remove these secondary affections of the tongue unless the treatment is continued during many weeks or months, but the external application cures them with the greatest rapidity. If a solitary deep fissure on the border of the tongue of a syphilitic person is distinctly associated with the presence of a rough and jagged tooth, the cure of the fissure will not be effected without removing the carious tooth. The healing of secondary syphilitic fissures is followed by scarring, and the scars are usually depressed and smooth, but they not infrequently become thickened and raised in milk-white lines and patches, which are very characteristic of past syphilis, and which may break down in later life with the production of new sores and fissures. These later manifestations, to which one feels inclined to give the name of secondary, although they appear long after the period of secondary syphilis is passed, are amenable to the same treatment as when they first broke out. Mercury and a solution of chromic acid act on them almost like a charm, and the most obstinate of them disappear under the com- bined influence of the two remedies. But the scars, both of the first and of the second outbreak, are permanent, and may break down again. The fissures of tertiary syphilis are usually much more TREATMENT OF SYPHILITIC FISSURES. 215 formidable than those of the secondary period. They may occur as the result of several slightly different pathological conditions, and are apt to vary, according to the nature of the condition which precedes them. Take as examples the following cases, three in number, all of which were under care at St. Bartholomew's Hospital. A man about forty years of age presents himself in the out-patient room with the complaint that within the last week or ten days some- thing has broken in the back part of his tongue, and when the tongue is protruded, there is a great and very deep tisMire in the middle ot its back part, about two inches in length. The edges of the fissure are drawn apart, and its depth is found to be at least an inch ; the sides are ragged and partly covered with slough ; the edges are a little under- mined, and the surrounding tissues are very slightly swollen and sodden, but very little indurated. There is a history of syphilis many years ago, and there are scars of past sores and thickening of the front aspect of each tibia. There can be no doubt that the fissure is the result ot the breaking of a large gumma, or of a collection of gummata. He is put on iodide of potassium, and the sore is simply cleansed as often as he can manage it with Condy's lotion, and, when it flags in healing, with an astringent solution. The healing is steady, but is very slow, and it is long before the fissure is obliterated. A scar remains, not corresponding with the depth of the great cleft, for the two sides joined together over a part of their extent, but still quite deep enough to be easily seen when the tongue is protruded. The second patient was a woman, who was for a while an inmate of Sir Thomas Smith's wards. She was younger than the man, for she was not more than two-and-thirty. She was well-looking, and bore no marks of syphilis unless upon her tongue, but there was no attempt to conceal the fact that she had suffered some years earlier from the disease. Deeply grooving the dorsal aspect of her tongue were two long and sinuous fissures, each from an inch and a half to two inches in length, or even longer. Each fissure branched here and there, and thus bore the appearance of a river on a map, with its tributaries joining it at intervals. When she protruded the tongue it was not difficult to see 216 DISEASES OF THE TONGUE. into some parts of both the fissures, for their edges sepa- rated, and allowed the deeper parts to be discovered, and then it was seen that they were at least a third of an inch deep, and in some parts deeper, a great depth when the extremely short diameter of the cleft is taken into account. The sides of the clefts were either quite perpendicular or a little undermined, and were not ragged and sloughy, as in the last case, but smooth and glazed, here and there redder and more sensitive ; and often . at the bottom of the fissure could be seen coagulated discharge or decomposing food. The parts of the fissures which could not be perceived by the natural separation or falling apart of the sides could easily be brought into view by gently separating them with the fingers. There was a little swelling and a very little induration of the borders of both fissures, and a narrow area immediately about them of smooth glazed dorsum, and beyond this the dorsum of the tongue was natural, and covered with papillae and with fur. The patient suffered exceedingly, for although there was no inflammation of the tongue, it was extremely sensitive, and there was profuse salivation. During her stay in the hospital she made very little progress towards recovery, for she could not take iodide of potassium, on account jof the iodism which it almost immediately produced, and none of the local applications which were ordered appeared to alleviate her suffering. Before she returned home she began to recover under small doses of the solution of bichloride of mercury and the local insufflation of a powder composed of morphia and oxide of zinc. The third patient was also a woman, about fifty years of age, who had had a very bad tongue for many years, and in whom the trouble recurred from time to time. Her whole tongue was strangely altered and disfigured ; long furrows and deep fissures ran down the dorsum from far back almost to the tip, and more than half-way back were crossed by similar fissures, extending nearly quite across the tongue. In front of and behind these transverse lines there were other transverse fissures, less deep and long, merely producing a puckering of the tongue, instead of appearing almost to cut the tongue across. The sides of DIAGNOSIS OF SYPHILITIC FISSURES. 217 the fissures were quite smooth and covered with unbroken mucous membrane ; nor was there any ulceration at the bottom of them. Between them the substance of the tongue bulged forth in smooth red musses, forming longitudinal rolls, which were broken and puckered by the "smaller tr.- 1 us verse fissures. There were no papill* or fur upon them, but the most central of them were roughened and warty. She was annoyed by frequent excoriation and ulceration of the prominent portions, which protruded between the fissures, but the fissures themselves seldom gave her any trouble. In her case treatment was directed solely to relieve the transient disturbance of the surface, for it was obviously impossible to remedy the general dis- figurement (Plate II., Fig. 2). It is important to bear in mind that the lymphatic glands are very seldom enlarged in association with syphilitic fissures, of whatever kind. Occasionally enlarge- ment of one or more glands occurs, but the enlargement is almost invariably due to some accidental cause. It is very unusual for a tertiary syphilitic fissure to be mistaken for any other disease than syphilis. It is so very rare to meet with deep and long fissures from other causes. Fissures, certainly, are formed in some cases of carcinoma, and sometimes in tuberculous disease of the tongue, but there is seldom any difficulty in distinguishing between these different fissures. Carcinoma does not appear in the first instance as a long, sinuous fissure or a deep and ragged cleft of the tongue. There is, in almost every case in which clefts occur, a distinct tumour, and the fissures are clefts in the substance of the tumour, which is not uncommonly a large, more or less prominent, ulcerated mass. It is evident, at the first sight, that the disease is a malignant disease, and not a mere fissured condition of the surface of the tongue. Tuberculous disease might possibly be mistaken for syphilitic disease in a very few rare cases. Such a great ulcerated cleft as that described in the first case is occa- sionally formed in tuberculous disease, but it is not until the disease is very far advanced and the signs of tubercle of other organs are clearly apparent. The tuberculous fissure is generally small, not long or generally deep, at 218 DISEASES OF THE TONGUE. first single, and bearing such characters as are described in the section on tuberculous ulcers. The associated signs, if there are any, are widely different in the two diseases, and the tongue is seldom without some other signs in the case of tertiary syphilitic fissures. The treatment of tertiary fissures of the tongue is guided by the rules which prevail in the treatment of tertiary affections generally. In addition to the general treatment of the case, the healing of the fissures may be often hastened by local measures, or if not materially hastened, may be rendered much more endurable by the patient, The use of chlorate of potash in the form of gargles of various strengths will probably suggest itself to most persons, and some patients are very much relieved by it. Borax-and-honey is also painted on the sore parts of the fissures with decided benefit. But there are other local remedies which are much more efficacious than these. In some persons glycerine of .borax and glycerine of tannin, either of the Pharmacopu-ial strengths or diluted to a greater or less degree, produce a rapid improvement in the condition of the sores. Other persons are more certainly and speedily . relieved, and their sores healed, by the use of gargles of black wash, either pure or diluted with liquor calcis. And in other cases, the application of weak solutions of the bicyanide of mercury with a soft brush at frequent intervals (three or four times a day), or in much stronger solutions once in two or three days, produces an excellent effect on the condition of the tongue. But the local applications from which the greatest benefit is derived are powders blown on the tongue, just as they are blown into the pharynx or larynx through an insufflator, or ointments applied in the manner described on p. 137, Chapter YIII. Pure iodoform, or iodoform and borax in various proportions, are excellent for the powders ; and if there is great sensibility of the affected part of the tongue, small quantities of morphia, from the twelfth to the sixth or more of a grain, may be added to each powder. The manner of employing these powders and other points connected with them are mentioned in the chapter on the palliative treatment of cancer and in the SYPHILITIC ULCERS. 219 chapter on ulcers, but it will not be amiss to direct attention in this place to the necessity for cleansing, as far as is practicable, the surface of the fissure before the application of the powder. This precaution ought, indeed, to be taken before any local application is made, otherwise the remedy does not reach the actual sore surface. Fissures especially require careful cleansing, on account of their depth and the tendency of food and other matters to collect in them. When the tongue is protruded and held gently out by means of a soft rag, the sides of the fissures often separate naturally, or if they do not, may be easily separated by pressing them gently asunder with the fingers. A stream of warm water, with a little Condy's fluid in it, should be allowed to fall very gently into the fissure from a syringe, or through an irrigator tube furnished with a nozzle. The stream clears out the material which has collected, and the surface of the fissure is clean, but it is still wet. It should be dried with a pellet of absorbent cotton-wool or with a tiny roll of blotting-paper, and then, while its sides are still separated and its deepest parts are exposed as thoroughly as possible, the powder should be dropped or blown into every part of it. The lack of these precautions is a great reason of the want of success which attends the use of many local remedies which otherwise might be of the greatest service. The same attention to diet which is paid in the case of other painful or sensitive conditions of the tongue should be paid here. (/) Syphilitic Ulcers. The ulcers of secondary syphilis are chiefly, if not Avholly, of two kinds : those which result from the breaking down or injury of mucous patches, and mere abrasions, or cracks, or fissured ulcers on the tip and borders. Many of the latter class are due to the ulceration of mucous patches, but some of them appear, at least, to have a different origin for instance, in the rubbing or bites of the teeth. The secondary ulcers, which are due to the breaking down of mucous patches, are generally easily recognised. They are seated on the tip or borders of the tongue; not because mucous patches are limited to these parts, but because the patches which are developed there are exposed to the rubbing and injury of the teeth, the more so that they widen or 220 DISEASES OF THE TONGVE. elongate the tongue at the part on which they stand, even though very slightly, and are thus pressed upon the adjacent teeth. The entire patch is not usually destroyed by the ulceration, but a part, sometimes a large part, of it remains to prove the origin of the disease. Usually the central part breaks down, and a starred or long, sinuous, ulcerated crack is produced, with pearly- white, rounded, smooth borders formed by the surrounding mucous patch. Beyond the pearly-white border, which is raised to the extent of half a line to a line, there is a red areola, narrow, and fading gradually into the natural colour of the tongue (Plate IV., Fig. 1). If the irritation is continued, and if the patient is of naturally feeble constitution, especially if he is strumous, the ulcer quickly extends, both widely and deeply, and ulcers are occasionally seen with the superficial area of a horse-bean, and a depth of a third of an inch, or with a much greater superficial area, but a much less depth. The deeper ulcers have a very unhealthy aspect ; their edges are sharp-cut, fissured, precipitous, and even undermined ; their surface is irregular, without healthy granulations, sometimes covered with slough ; the sur- rounding parts are infiltrated, but rarely much harder than the natural consistence of the tongue. It is worthy of note that these ulcers, however they are produced, are very seldom much inflamed. Even when they are distinctly due to irritation or injury, the inflammation is insignificant compared with that which is associated with ulcers pro- duced by the same kind of irritation or injury in a person who has not had syphilis. We are speaking now of the general rule, but it would not be safe to deny the syphilitic predisposition in every instance in which an ulcer of the tongue is much inflamed, for the presence of syphilis does not afford an immunity from acute inflammation, whether of a part of the body actually syphilitic or not. Acute inflammation is evidently not, however, a necessary factor in the production of even deep and ugly sores upon the tongues of persons with secondary syphilis. The secondary affections of the second variety appear in the form of small excoriations of the dorsum of the tongue, generally near the tip and edges, or of the tip and edges DIAGNOSIS OF SYPHILITIC Z7iC' /;/>. 221 themselves, without any very definite characters, without inflammation, and often without any signs by which they can be recognised as due to syphilis or any other constitutional malady. They appear also in the form of small cracks or fissured ulcers on the tip and borders of the tongue, and these, again, are chiefly noticeable for the absence of any distinctive characters and of surrounding inflammation. Sometimes the disease of the tongue is limited to one or two cracks or excoriations ; sometimes the borders are affected in every part ; but in neither case is there any essential difference in the appearance of the sores. It is very unusual to find these cracks and fissures on the dorsum, a fact which speaks strongly for the necessity of another cause than syphilis at work in their production. Syphilis is the predisposing, the rubbing by the teeth the exciting cause. The ulcers of secondary syphilis may remain a long while unaltered, or may slowly extend. Whether they are due to the breaking down of mucous patches or not, and whether they are inflamed or not, they are almost always sensitive, often extremely so. This, and the small tendency they show to spontaneous improvement, make the patients who suffer from them very uneasy. Apart from the actual distress they cause, they are in many cases a continual remembrancer of the syphilis to which they owed their origin. On these various accounts patients are most anxious to be rid of them. The diagnosis of these various secondary syphilitic sores is in most instances easy, in some instances almost impossible- Those which are due to the breaking down of mucous tubercles are easily recognised by the remains of the ulcerated tubercles, and by the other signs of syphilis which are almost invariably present on the tongue or some other part of the mucous membrane of the mouth. If the mouth is otherwise free from syphilis, it is more than probable that mucous tubercles will be found around the anus, or nodes upon the tibia, or inflammation of the iris. The entire absence, or the vi TV modified character of the surrounding inflammation, may be almost termed a sign of syphilis ; and, in some cases, at least, a history of syphilis will be obtained, and there will still be induration of the penis or soreness where the initial lesion of syphilis appeared. The diagnosis of the excoriations, 222 DISEASES OF THE TONGUE. cracks, and fissured ulcers which are not preceded or accompanied by the presence of mucous tubercles, or any other marked sign of syphilis on the tongue, is more or less difficult according as there is or is not a clear history of syphilis or symptoms of present or past syphilis in the mouth or some other part of the body. It has already been stated that the characters presented by these lesions are not distinctive of syphilis ; but the occurrence of several or many of them on the tongue, and the almost entire absence of surrounding inflammation, are very suggestive of syphilis, especially if the teeth are not manifestly diseased. In some instances the diagnosis is made rather by the absence of the signs of other disease, and by the obstinacy of the affection, than by the positive signs of syphilis. The treatment of these secondary affections is, fortunately, for the most part, very rapidly successful. But to obtain a rapid success it is absolutely necessary, in the very large majority of cases, to use local as well as constitutional measures. If these ulcers occur in the early period of secondary syphilis, or if they occur in persons who have not been treated sufficiently with mercury (in fact, in the large majority of cases), three grains of hydrargyrum-cum-creta should be taken twice a day, and the sore places on the tongue should be painted at least three or four times a day with a camel-hair brush dipped in a solution of ten grains of chromic acid to one ounce of water. The effect of this treatment on the ulcers is marvellous : they cease almost at once to be painful, and in the course of a few days most of them are well. Of all local applications for secondary affections of the tongue, none appears to produce nearly so salutary an effect as chromic acid. The healing of most of the secondary ulcers leaves scars, but the scars are seldom very deep or extensive. Still, they are plainly visible, smooth and shining marks, of silvery or leaden hue, slightly depressed, taking the form of the furrows, lines, and cracks of the ulcers. The margins of the tongue are in this manner often puckered and roughened, and changed in colour, affording a permanent record of past syphilis, which is not without use in the diagnosis of later affections of the tongue. GUMMATOUS ULCKI:-. :-J3 The ulcers due to tertiary syphilis are far more formid- able than those of the secondary period, and, no matter whether they be superficial or deep, are apt to leave behind enduring records of their passage in the form of deep furrows and extensive puckering. They are nearly always preceded by gummata, but the gummata may be overlooked even when they have probably existed some considerable time, and have been of large size, for they are not usually painful, and are not sources of inconvenience in eating or in speaking (see nodes and nodules). An example of the extent of some tertiary ulcers is seen in Plate IV., Fig. 3. It might fairly, having respect to the size of the tongue, have been described as a vast and deep cavity, for it was at least three-quarters of an inch deep ; yet the patient declared it had not been preceded by the formation of a tumour, but that a slight swelling had appeared almost suddenly a week before, and that it no sooner appeared than, Avith little or no distress or pain, it burst, leaving the cavity which he exhibited. The deep and large gummata produce, in breaking, ulcers which look formidable, but they are in reality often less so than those left by the superficial gummata or the small and numerous gummata, which are more deeply placed. When a large gumma softens and discharges, it usually opens through a comparatively small opening, but the opening quickly enlarges by melting down of the infiltrated and unhealthy tissues immediately around it (Plate IV., Fig. 2). A cavity is exposed, with precipitous, ragged borders, which are often undermined, with a ragged and sloughy surface, with perhaps, but not always, a large slough in its interior, with thickened and generally hardened tissues for some distance around it. It may vary much in shape, may be angular, or cleft-like, or quite irregular, but very rarely exhibits the typical rounded shape of a gummatous ulcer of other parts of the boJy. After a while the sloughy and ragged appearance of the walls and surface disappears; it is replaced by a smooth surface, with few or imperfect granulations ; the surrounding parts remain for a long time thickened and indurated, and the appearance of the disease is that of an indolent and chronic ulcer. The diagnosis of gummatous ulcers is beset with great 224 DISEASES OF THE TONGUE. difficulties in certain cases, particularly when there is a single ulcer : they may be taken for tuberculous and cancerous ulcers : and it is not always easy to be sure whether an ulcer is due to the destruction of a giunnia or to the injury of a tooth. It will suffice to point out here that all tertiary affections of the tongue have as great a liking for the dorsum as for any other part, and not infrequently occur far back in the middle of the dorsum ; and in this respect they differ from all the ulcers for which they are liable to be mistaken. They may also form in the floor of the mouth, beneath the fore part of the tongue. Gummatous ulcers are much more common in men than women, and attack persons who are at or about the middle period of life, but they may occur much earlier, and have been observed, though rarely, in the tongues of children as the result of inherited syphilis. Associated signs of syphilis may be observed in persons who have gummatous ulcers, it not in the tongue, yet in another part of the body. But the presence of as- sociated signs cannot be relied on, and the history is often quite misleading. The lymphatic glands are not affected in association with gummatous ulcers. Gummatous ulcers may heal spontaneously, but they rarely do so. They may remain in an indolent condition for an almost unlimited period, neither extending materially nor healing, unless it be over a small area here and there. They may become inflamed and slowly extend, or may become phagedenic, and, quickly increasing, may eat away a large portion of the tongue. The course which they pursue will depend very much on the condition of the patient, and, to a less degree, on the local conditions which surround the ulcers. The effect of lowered health upon them is proved, in an inverse manner, by the amelioration which is conse- quent on improvement of the general health, even though no anti-syphilitic remedies have been employed. The most rapid cures are effected by a combination of tonic and anti- syphilitic treatment. 225 CHAPTER XII. TUMOURS AND CYSTS OF THE MUCOUS AND SALIVARY GLANDS; SALIVARY CALCULI. Hypertrophy: (a) Congenital, (It) Inflammatory. Tumours. Obstruction Cysts, or Rauula : (a) Cause, (6) Subliugual, (r) Incisive, ( Myxochondrosarcoma. None. 4 Adenoma and adenochondroma. None. 1 Lymphosarcoma. None. 15 Endotbelioma. 33 Endothelial and mixed tumours. 4"> 6 insufficiently described. Other views have been held, such as that some of these tumours are cylindromas, produced from the epithelial cells of the alveoli and ducts, whilst the connective tissue outside also takes part in the tumour formation, and undergoes car- tilaginous, myxomatous and other degeneration. Whatever be the pathological explanation of these tumours, they are in most cases clinically benign, malignant sarcomas and carcinomas being much the rarest tumours. They commence generally in the submaxillary gland, to the side and below the tongue, and bulge beneath the jaw. They grow very slowly, taking one to three years to reach the size of a tangerine orange from the time when they were first noticed to be about the size of a nut. They shell out easily, 1 Mving healthy gland substance behind, or if the whole gland is taken away with the tumour it is found spread out over the capsule, but not markedly altered. It is remarkable that these tumours of the submaxillary gland are far more common on the left side. They arise in young adults, in women as often as men, but are also seen in old people. .Most, important of all, they do not recur after removal, if that takes place whilst they are still encapsuled. Although it is common for the patient to give a history of having noticed the tumour for one to four years, this time may be much extended. Curtis described the case of a woman, aged twenty-four, with a tumour the size of a tangerine orange below the jaw, which had existed eight or nine years. In Lane's case, in which the tumour had existed four years, it was found on removal to be an encapsuled tumour with the 230 DISEASES OF THE TONGUE. remains of the salivary gland wrapped round it. In Beadle's case of an old woman, aged seventy-six, in which the growth had existed a long time, there was a tumour two inches in diameter, with the submaxillary gland attached. It con- sisted of rnyxomatous tissue interspersed with masses of connective tissue cells, without any cartilaginous or glan- dular appearance. When these tumours have lasted a good time, especially in old people, they become cystic and may have extrava- sations of blood in them, and altogether approach the appearance of cystic goitres. Hayes described the post- mortem appearances of a woman who died at the age of seventy-three with an enormous cystic tumour under the jaw which had commenced thirty years before and had grown steadily. It measured fifty inches in circumference, weighed forty-seven pounds, and had partly absorbed the lower jaw by simple pressure atrophy. It could easily have been removed, for it was well encapsuled. and was only adherent to the skin, in which were large veins. But these tumours do not always remain benign : after remaining indolent for some years a change may set in, extension takes place through the capsule to the surrounding parts, a glandular enlargement commences and spreads down the neck, and death soon follows. If the case is not seen until this change has set in recurrence will probably follow quickly upon removal. We have seen more than one instance of this kind. The rare conditions of teleangioma may present surgical difficulties owing to the number of vessels supplying them. Under the title of angiofibroma Fischer describes a tumour growing for a year and a half in a man aged thirty-seven. It was first noticed under the left jaw, closely connected with the base of the tongue, gradually bulging more and more into the neck, as well as forming a tumour in the mouth. At the time of operation it had grown so as to receive a communicated pulsation from the carotid. An attempt was made to remove the tumour, enormous veins were met with, and the patient died on the table after the operation had lasted an hour and a half. Diagnosis of Submaxillary Gland Tumours. -- The tumours described have generally been met with in the RANULA. 231 position of the left submaxillary gland, although perhaps some of the tumours may have grown from adjacent por- tions of the sublinguaL They have generally been first noticed when about the size of a nut, felt by the patient under the angle of the jaw, as a hard nodular tumour, and con- tinuing to grow slowly. Their origin is unconnected with injury or inflammation, and the tumour is single, whereas in lymphatic gland enlargements more than one is generally enlarged, the commencement is inflammatory, or is accounted for by a carious tooth, etc. The tumour is partly movable along with the salivary gland. Removal is always indi- cated ; and, if the tumour is not encapsuled and is difficult to define, it is safe to remove the salivary gland. Even when the tumour is vascular the operation will present no diffi- culties if undertaken early, the vessels surrounding the tumour being first of all ligatured. :). Obstruction Cysts of the Mucous and Salivary Glands ; Ranula. The name " ranula " has some fanciful origin, of which the explanation is lost, and none of the attempts which have been made to supply one has met with general acceptation. Did the swelling under the tongue seem like the head of a " ranula," " little frog," or " tadpole," the salivary papilla? like its eyes, the fringe on either side of the frsenum like its gills '. did the ropy mucus appear to be the mother substance of the swelling, just as the tadpole comes out of the ropy frog spawn ? Charles Bell said that a rauula was like a frog's belly ; but others likened it to a frog's tongue. The name has proved unfortunate, and the source of much unnecessary confusion. Many totally different con- ditions have been included under it. If the word is used, it should be applied to any obstruction cyst of the mucous and salivary glands under the tongue. The different forms of ranula will then corre- spond to the glands, submaxillary, sublingual, Blandin's, and the incisive gland, and will vary according as the obstruction is acute, intermittent, or chronic, and according to the direction in which the cyst tends to bulge. (a) Cause of the Obstruction. The chief cause of the 232 DISEASES OF THE TONGUE. obstruction appears to be an inflammation taking place within the ducts, giving rise to the formation of plugs of inspissated mucus in which calcareous material may become deposited. Possibly this may be started by micro-organisms passing into the ducts from the mouth, as staphylococci have been found, but no direct connection between inflam- matory conditions in the mouth, carious teeth, tartar, etc., has been noted. Nor do inflammations, such as mumps, if the salivary glands are affected, lead to ranula and calculus- Small foreign bodies, bits of grain or husks of corn, fruit seeds, such as those of raspberries and currants, are said to penetrate into the ducts, but this causal connection has but seldom been demonstrated. Tumours pressing on the ducts certainly cause retention. Some ranulas arc clearly congenital (Lannelongue), presumably due to mal- formation of ducts, and perhaps a malformation is a more general cause than is supposed ; for although ranula and salivary calculus generally appear in adults, yet they are seen sometimes in children at ages of nine and twelve. The result on the gland behind the obstruction is atrophy with an increased interstitial inflammation. Suzanne says that ranula is a myxomatous degeneration of the gland, and is not due to duct obstruction. Another theory, not widely held, is that a ranula is a cyst of new formation. (6) Sublinyual Ranula. The commonest form of ranula is that which arises in the sublingual gland (Fig. 3. p. 8), and which gives rise secondarily to atrophy of the rest of the gland, and to more or less pressure on the submaxillary or W barton's duct, but along which it is possible to pass a probe (Baker). It is generally painless in its original course, and rises up in the floor of the mouth between the tongue and the jaw, having a translucent appearance, with large veins on its surface. It is tensa and fluctuates, but does not pit on finger pressure; it does not generally bulge in the neck, and cannot therefore well be felt by bimanual palpation. It may enlarge until it pushes up the tongue, and causes difficulty in speech, feeding, and respiration, or bulges almost out of the mouth. When a ranula from protruding in the floor of the mouth projects into the submaxillary region below the angle of the jaw it is probable that it has POSITIONS OF RANULA. 233 originated in the intrabuccal portion of the submaxillary gland, and not in the sublingual. Morestin figures a dis- section to show prolongations of sublingual lobules between the fibres of the mylohyoid muscle appearing on the under surface. He conjectures that a ranula may form in this position, and thus be met with between the lower jaw and the hvoid bone below the mylohyoid. A calculus may form in connection with the ranula and suppuration may be set up spontaneously, or as the result of some ineffective topping : then pain will be caused. (c) Ranula in the Position of the Incisive Gland. In this position the ranula is just behind the lower jaw (Fig. 3, p. S) and pushes up the fnenum. The origin of such ranulffi was at one time assigned to a bursal sac by Fleischmann, but this bursa has no existence (see p. 10). It is difficult or impos- sible to distinguish one arising in the incisive glands from a bilateral ranula of the sublingual gland. Paget describes a congenital cyst which, immediately after birth, was so large as to nearly suffocate the infant ; it was, therefore, imme- diately tapped, and a tumbler of clear watery fluid drawn off. The cyst was tapped twenty times during the first year of life, further treatment was not allowed until the child was aged four. A cyst then hung from the mouth nearly down to the sternum, covered Avith a harsh dry cuticle approaching that of skin ; the muscles of the tongue were spread out over its posterior and upper aspect. The teeth, lower jaw, and lips were all everted. The cyst was removed without difficulty. It contained turbid yellowish fluid, and there was a well-defined wall of fibrous tissue, lined by granulations without trace of epithelium. (d) Ranula in Bbindiv'* Glmid. A more clearly denned form of ranula is met with in Blandin's gland (Fig. 4, p. 9). The tongue can be protruded with the cyst attached underneath its tip, leaving the floor of the mouth free. Yon Reckling- hausen and Sonnenburg showed by dissection that a ranula occurred in connection with this gland. The case described by Foederl is very clearly a cyst due to congenital obstruc- tion of a duct of Blandin's gland. Immediately after the birth of a fully developed child a transparent, fluctuating. pear-shaped mass was seen, fixed underneath the tip of 234 DISEASES OF THE TONGUE. the tongue, its upper surface being level and continuous with the dorsal surface. The floor of the mouth and the salivary papillae were quite free, and saliva was secreted freely from them when sugar or citric acid was put on the tongue. Egg-white-like fluid escaped on cutting into the cyst ; an excised portion of the cyst showed columnar cells in places : in others, the cells had been detached and the wall of the cyst was formed by a connective-tissue stroma evidently the cyst- wall was formed by a dilated duct. In Godlee's case, in which a tumour was cut out from the tip of the tongue, a calculus formed the centre of the tumour, surrounded by glandular substance and round and spindle connective-tissue cells, which were concluded to be sarcomatous. Here a malignant change had commenced around a salivary calculus. (e) Ranula of the Submaxillary S which had entered the opening of Wharton's duct. Du Cane's case was ,-m extraordinary one. A man in good health was eating his dinner, Avhen suddenly a swelling began to form under the tongue on each side, pushing the tongue backwards until only the under surface of the tip was visible. He became unable to swallow his saliva, and began to suffer from dyspnoea. Two large oval swellings presented, of a pale pinkish colour, with translucent walls, that on the right side causing also a bulging beneath the jaw. Immediately upon incision and the escape of an ounce of saliva on each side, relief was given. There was no calculus or stenosis in Wharton's duct, and the trouble did not recur. ///'< i-nilttent Form. In some cases the distension is intermittent, the discharge by the salivary papilla taking place spontaneously, or being aided by manipulation, the tumour disappearing after the patient has pressed upon it. This is very often due to a small calculus, which is easily movable in the duct, and only causes obstruction when it is arrested just within the orifice. L'lironic Form. If the obstruction is in the neighbour- hood of the salivary papillae a distension of Wharton's duct will be found with or without any swelling below the angle of the jaw. The tumour has an elongated shape, and there is no flow of ! aliva from the corresponding salivary papilla when the surface has been dried and the tongue touched with a glass rod dipped in citric acid. A probe cannot be passed along the duct until after a puncture, when ropy saliva escapes. On then inserting a probe, a salivary calculus may or may not be met with. If the retention involves the external portion of the gland, a cystic swelling forms in the submaxillary triangle below the angle of the jaw. It may intermittently subside owing to the communication with the mouth not being entirely shut off, or may continue to enlarge. One of the largest size is described by Sir James Paget. A flaccid, half-filled cyst occupied subcutaneously the side of the face and neck, extending from the malar bone and zygoma to the cricoid cartilage, backwards to the anterior border of the masseter, and forwards to the middle line below the jaw, and nearly to the angle of the mouth. It had existed four years, and had intermittently discharged through L>36 DISEASES OF THE TONGUE. \V barton's duct. The cyst was drained from below, and after free suppuration shrunk to scar tissue, and permanently healed. 4. Salivary Calculi. A salivary calculus consists chiefly of phosphate of lime, with some carbonate and about 5 per cent, of organic matter. It forms a spindle-shaped concretion, its shape being deter- mined by the duct in which it forms. This is generally the .submaxillary duct, but occasionally a calculus is met with in one of the other ducts e.g. that of the gland of Blandin (Fig. 4, p. 9). It apparently forms in connection with a plug of inspis- sated mucus by the deposition of lime salts : and its commence- ment and early development being usually painless, it may reach a considerable size without being noticed. It may then cause tenderness on contact, impair mastication and speech, or set up suppuration, and become buried in a fungating mass of granulations or surrounded by a mass of scar tissue. The size reached may be that of an almond, the extreme size reached being in Puzey's case, one and a half by one inch by half-inch, and the weight 7'6 grms. : in Power's case, one inch in length and half-inch in circumference, with a weight of 4 - 4 grms. The stone may be easily ielt through the wall of the duct, which tits it tightly like a glove, and from which it is with difficulty drawn out, owing to the closeness with which the wall of the duct surrounds it. In another form, the duct is distended to form a ranula, and it is only when the fluid has been let out that a stone is found loose in the cavity. Then suppuration sets in, there is much pain, and the pus ma}- be discharged into the mouth or through the skin under the jaw. A fistulous tract forms with fungating granulations, from which a foul discharge escapes. Through the fistulous tract or the granulations the calculus may be felt by a probe or needle. If the stone only excites a slight degree of chronic inflammation, the walls of the duct gradually thicken around it until a hard tumour has arisen, and the stone in the centre escapes detection unless the centre of the mass is explored by a needle. A rarer form of calculus formation takes place in the secondary ducts of the gland, and calcareous masses like rice grains are formed, which may escape spontaneously DIAGNOSIS OF EANULA AND CALCl'Ll's. 237 through Wharton's duct ; or, when an incision is made into the swelling, many of these small calculi are squeezed out. A case of the kind was seen by Spencer. A maid- -' i \.i in had suffered much from pain and presented a very tensely distended duct of Wharton on the left side with swelling and tenderness of the gland under the jaw. The duct was incised after applying cocaine, and a number of calculi, like rice grains, squeezed out. There followed several re-collections of the small calculi, and, finally, the gland wa excised. The section made from the excised gland shows chronic interstitial inflammation with spheroidal collections of partly calcified mucus in the secondary ducts. The diagnosis of ranula follows from the description : A more or less tense, thin-walled, semi-translucent, fluc- tuating swelling in the position of one of the mucous salivary glands. The diagnosis of ranula from dermoid cyst has been often dwelt on at length; it is generally very ea^y. A dermoid cyst is generally more doughy to the touch, is not translucent, and can be felt through the skin behind the lower jaw. A ranula of congenital origin must be dis- tinguished from a congenital cystic hygroma in the neck bulging up towards the floor of the mouth. A calculus is very difficult to diagnose when it has become surrounded by a mass of firm, fibrous tissue, and when, after suppuration, there has been a bursting of the abscess and the stone lies under a fungating mass of granulations. There are cases in which the presence of a calculus can only be diagnosed by exploring with a needle or by an incision. Kiittner mentions five cases in which a tumour of this kind was explored and a calculus found in the midst of a hard, inflammatory mass. In only one of the five had a preliminary diagnosis been correctly made ; in the other lour, malignant disease was supposed to be present. All three cases described by Hulke gave rise to a suspicion of cancer until the tumour was explored. The neglect of such a preliminary exploration has led to unnecessary excision of portions of the tongue, the tumour proving afterwards to be a calculus surrounded by a mass of dense fibrous tissue. Kappeler describes the removal of a tumour, supposed to be malignant, extending from the 238 DISEASES OF THE TONGUE. symphysis of the jaw to the hyoid bone, set up by inflam- matory thickening around concretions. The Treatment of Ranula / Calculu*. Many small and superficial cases are cured by simple measures. A seton may be passed which will cut itself out about the sixth day, leaving the open sac to suppurate and shrivel up. Another method is to excise a piece of the cyst wall and wipe out the cavity with chloride of zinc or nitrate of silver. The inner wall is wiped away or sloughs, and healing follows. Puncture only, as also the injection of iodine, are useless measures. Many cases are not to be cured by such simple means, especially when the sac wall still preserves its mucous surface, and then excision is required ; also excision of a ranula is necessary when simpler means have failed. Care must be taken to completely remove the whole wall, for a small piece left behind may keep up a fistulous track. The tumour can almost always be removed from the mouth. The tumour may be dis- sected out without opening the sac, or a small opening may- be made, the contents allowed to escape, and then a piece of sponge is inserted in order to distend the cavity of the cyst and make excision easier by defining the margin. In such cases, a general anesthetic is required. Calculi are removed by cutting down upon them freely in the line of the duct and extracting them by forceps and a small scoop. The operation can often be performed with cocaine or under nitrous oxide gas, but a general anaesthetic may be necessary. An external incision is only called for in order to excise the outer portion of the submaxillary gland. The incision should run well under the ramus of the jaw, and a ligature be placed at the junction with the inner portion of the gland and Whar ton's duct in order to avoid a mucous fistula. :>39 CHAPTER XIII. CYSTS OF THE TONGUE. Epidermal or Dermoid Cysts and Fistula} Mucous Cysts Blood Cysts Parasitic Cysts : Cysticercus Cellulosae and Echiuococcus Cysts Chronic Abscess. 1. Epidermal or Dermoid Cysts. These cysts were formerly confused with the obstruction cysts of the mucous and salivary glands or ranuhe, with the cysts which form in connection with the thyreoglossal tract and with cold abscesses. They are characterised by a lining of stratilied epithelium, outside which is a fibrous capsule ; there are frequently present appendages of the skin, sebaceous glands, and hair-follicles. The epithelial lining can always be found on micro- scopical examination, although it may be obscured, and partly, yet not wholly, destroyed by suppuration. The lining is epidermal; there is frequently little or no evidence of any formation of true derniis, the fibrous wall outside the epithelial layer being of inflammatory origin, but there may be papillte and more or less evidence of dermis. How- ever, " dermoid " is the common term used. The contents of these cysts consist of epithelial cells, more or less broken down, sebaceous material secreted from the glands, and often of hair, generally short and downy. The sebaceous material undergoes variations in consist- ence; it may look like porridge or become of the con- sistency of white of egg, or become partly crystalline, showing crystals of cholesterin and fatty acids, or become oily, and set after growing cold. The odour is that of the fatty acids which characterise sebaceous cysts. These cysts, no doubt, have their origin in groups of epithelial cells separated off in the earliest stages of embryonic life, and remaining enclosed (" sequestrated " is 240 DISEASES OF THE TONGUE. the term used by Bland Sutton) in the connective tissues formed bv the mesoblast. Groups of epithelial cells, when detached and carried into the connective tissues by injury, give rise to epidermal cysts, such as are met with on the fingers. The separation of the epithelial cells which will later form the cyst must occur in the very earliest stages of embryonic life, when the layers of the epiderm and endo- derm are just beginning to be separated by the meso- blast. The cysts may occur in the middle line from the symphysis of the lower jaw to the body of the hyoid bone in the line of the deeper part of the septum of the tongue. They are connected, therefore, with the closure of the epiderm along the middle line, which will come to lie between the lower jaw and the hyoid bone. They are found along the line of the septum, the origin of which, as the skeleton of the tongue in lower animals, has been referred to, also the fact that the cells which give rise to the primitive bone of the skeleton, e.g. of the skull, are a part of the mesoblast most closely connected with the epiderm (Chapter I., p. 10 ft seq.). A dermoid cyst may have a lateral position, being found below the angle of the jaw, near the cornu of the hyoid bone. In many cases this has been found to be really a secondary position by extension from the middle line. When really primary the cyst, in all prob- ability, originates in connection with a lateral branchial groove. The evidence that a dermoid cyst is really congenital in origin is often defective. The fact that the cyst is only noticed in adult life, and as late as sixty years of age, may, at first sight, seem to oppose a congenital origin. But there is now ample evidence that a dermoid cyst may remain small and quiescent for an indefinite period. Moreover, in some patients at least, a small lump has been noticed at birth. In Flinn's case a small lump the size of a pea was noted on the second day after birth, lying beneath the tongue, which slowly enlarged to the size of a nut. When the patient reached the age of twenty-eight the tumour again began to grow until it filled the mouth and projected beneath the jaw, having a diameter of five or six inches, PLATE VII. Fig. 1. Tertiary syphilitic plaque of dorsum of tongue in a man, aged 30 years. Two gummata on right border commencing to shrink. Fig. 2. Lymphangioma of the whole thickness of the anterior half of the tongue in a boy, 7 years old. Fig. 3. Carcinoma of the left border of the tongue of a man, aged 40. Fi a 1 3 B CYST. 241 and producing prostration and dyspnoea. In Green's case the cyst was the size ' of a small bird's egg at ten years of age. At twenty-nine, the man could not close his teeth at all, and only with difficulty his lips, and there was huskiness and dyspnoea. Stephen Paget gives the results of an exact microscopical examination of a dermoid cyst, three-quarters of an inch in diameter, removed from under the tongue of a little girl by Butlin. Its inner surface consisted of true c. c. Fig. 15. DlAGEAM OF A SAGITTAL SECTION THROUGH THE TONGUE. The diagram serves to indicate the two common situations of (l)and (2) dennoid cysts and also the parts which are involved by compression when such cysts or other tumours of the tongue become much enlarged. S. Base of Skull. V. I., II., III., IV., V. Level of Altas, Axis and following vertebrae. A. C. Arylenoid Cartihige. T. C. Thyroid Cartilage. C. C. Cricoid Cartila;,'.-. Myh. ilylnhyoid. Gh. Geniohyoid. Glig. Geuiohyoglossus. E. Eustachian tube. P. Hard and soft palate. L. J. Lower Jaw. skin with a few short hairs. The papillae of the corium and the part of the corium lying immediately under the rete malpighii was loaded with black pigment, whilst the rete malpighii itself was free from pigment. It is curious to note that the skin under the chin of the girl would be the seat neither of pigmentation nor of hair-follicles. A dermoid cyst is usually situated in the middle line beneath the main substance of the tongue, between the geniohyoglossi muscles and above the mylohyoid. Usually, when the case is presented for operation, the tumour bulges beneath the chin, and may be of the size of a pullet's egg, turkey's egg, or even that of the closed fist. The cyst is generally (Fig. 15) attached by a firm, fibrous 242 DISEASES OF THE TONGUE. band to the lower jaw, about the genial tubercles; or to the body of the hyoid bone, but it may have no attachment to either the one or the other. An instance of this is to be seen in the College of Surgeons' Museum (No. 252) : the cyst lies in the middle line beneath the main mass of the tongue, between the geniohyoglossi muscles; its contents resemble the hard-boiled yolk of an egg, and the cyst is lined by squamous epithelium. If the cyst bulges into the floor of the mouth it has a yellowish or orange aspect, as distinguished from the bluish look of a ranula. If examined bi-manually, with one finger in the mouth and another under the chin, fluctuation may be distinguished, not so clear as in the case of ranula, but more doughy ; and the wall may pit on firm pressure. The symptoms vary with the size of the cyst; as it enlarges, speech becomes less clear ; there is difficulty in swallowing, with drivelling of saliva and weakness from want of food, ultimately dyspno3a from pressure backwards of the epiglottis (Fig. 15). The complications which ensue are : inflammation with thickening of the wall, also suppuration, which is rarely spontaneous, and is usually provoked by unwise treatment, as a consequence of which rupture may ensue- and a fistula open, either into the mouth or below the chin. The diagnosis of a dermoid cyst is generally made without difficulty. Its position, its yellowish colour when it bulges in the mouth, and pitting on pressure are the special signs. The diagnosis from ranula has been already mentioned; that from salivary calculus and its complica- tions may be made by the relative softness of a dermoid cyst and by the absence of signs of inflammation. The only other affections for which it may reasonably be mis- taken are very soft, innocent tumours, which are excessively rare in the situations where dermoid cysts occur. Dermoid Fistulce. A number of fistulre have occurred opening into the mouth or on to the neck, owing to attempts to cure dermoid cysts by puncture, incisio.n, or seton, without removing the cyst-wall. A remarkable fistula in the middle line of the tongue is described by Furnival. A man, aged forty-two, had a EXCISION OF DERMOID CYSTS. Jfc! swelling under the tongue for a year and a half which was pricked and cauterised, afterwards continuing to discharge intermittently. An ill-defined lump, the size of a hazel nut, remained on the tongue and projected underneath, midway between the tip and the floor of the mouth. From this a tistulous tract led back towards the foramen cajcum, which was not patent. The tract was the size of and felt like the vas deferens. It was found after excision to be lined by stratified epithelium surrounded by connective tissue. Treatment. A derrnoid cyst should only be treated in one way, viz. by complete excision. If the tumour is well to the front, it may generally be removed through the open mouth, unless it is of very large size. Indeed, we have more than once succeeded in removing a lateral dermoid near the angle of the jaw, through the mouth. The separation of the cyst-wall is accomplished, after division of the over- lying tissues, with the tinger, assisted by a blunt, slightly- curved elevator. The fibrous band which unites it to the bone may need division with scissors. The cavity is plugged with iodoform gauze. Care must be taken to remove the whole of the cyst-wall, or a fistula will remain. A general amesthetic is almost always necessary. The patient "should be placed on one side, with the head forwards and downwards, and the mouth be kept open by a gag. If a dermoid cyst is of very large size, or so situated that it may be dangerous or very difficult to remove it through the mouth, it must be taken out through an incision behind the lower jaw. A linear incision is made between the chin and the hyoid bone, the median raphe of the mvlohyoid divided, the geniohyoglossi retracted, the cyst (unless small) punctured and evacuated. The wall can then be separated by blunt instruments, except for adhesions to bone, which have to be divided with knife or scissors. A lateral dermoid requires a different incision, in accordance with its position ; but the principle of the operation is the same. Dermoid fistulae must be completely excised, and lor this a careful dissection is necessary through a sufficiently wide incision. 244 DISEASES OF THE TONGUE. 2. Mucous Cysts. These might be expected to frequently occur In con- nection with the numerous mucous glands, yet with the exception of those which will be referred to on the base of the tongue behind the circumvallats papillae, the occur- rence is rare and perhaps has been considered too trivial to have been put on record. They are probably obstruction cysts, similar to those which occur on the lip, translucent and containing a clear viscid fluid. The contents distinguish them from the only things with which they are likely to be mistaken, viz. cysticercus and echinococcus cysts. After painting with cocaine the wail should be seized by forceps, and cut off level with the tongue by scissors curved on the flat. 3. Blood Cysts. A cyst containing blood is a very rare condition, but latterly several cases have been described in which the very vascular cysts and tumours at the foramen caecum in connection with the thyreoglossal tract have contained blood. In fact, this is one of the special peculiarities which practically renders them identical with the adenomatous cysts and tumours of the main thyroid gland itself. A case which appears to be of this kind is related by Bryant in the 41st volume of the Guy's Hospital Reports. The patient was a girl, eighteen years of age, who had a fluctuating swelling at the back part of the tongue, reaching as far forwards as the circumvallate papillae. It was smooth and rounded. It had been noticed only four or five months, and during that period had slowly increased in size, but Bryant thought it had probably been there for a much longer time. During the last ten days before admission she had bled to a considerable amount from the nose and mouth. The cyst was opened, but only blood escaped. The cavity was plugged with lint, and by-and-by filled up from the bottom. Some time afterwards she came to the hospital to report herself as well. Bruce Clarke exhibited a patient in whom there was a blood cyst on the front of the tongue which had formed in a degenerating naevoid tumour. At the first tapping it PARASITIC CYSTS. 245 yielded serous fluid, the next time blood, and quickly refilled. He proposed to excise it. Extravasations of blood from the dilated veins and capillary tufts is a common feature of macroglossia and Lymphangioma. 4. Parasitic Cysts (cysticercus cellulosse and echino- coccus). These cysts were reserved for mention in this place when other parasitic affections of the tongue were men- tioned. Always rare, the disease will by-and-by become of historical interest only, since it is understood that the parasite is killed by properly cooking the food, and the tapeworm will not be propagated if dogs are prevented from eating the carcases of animals affected by hydatids. Cysticercus Celluloses. The cysticercus is deep-seated in the muscular substance of the tongue. Roser, in 1861, said that he had met with several cases, and had once made a correct diagnosis. A round, firm, or quite hard, circumscribed nodule, of the size of a pea or cherry, was found situated more or less deeply in the muscular sub' stance. Shillitoe, in 1863, found three cysts in a child of eight. One cyst occupied the entire thickness of the tongue, the others projected on the upper, under and lateral surfaces, forming rounded, firm, semi-fluctuating elevations. The cysts had a translucent lining membrane with clear fluid containing cholesterin and bodies the size of mustard seeds with disc-like heads, but showing no booklets. In Lannelongue's case a cyst, the size of a small pea, on the dorsum of the tip of the tongue of a boy aged two and a half, had a bluish white, translucent wall, within which was a living cysticercus with a double row of booklets. Broca has described a similar case. Hofmokl, in 1877, mentioned the case of a boy from whose tongue a cyst was extirpated which proved to be a cysticercus. Two little nodules in the skin of the breast were possibly of the same nature, but were not further examined. Molliere saw a man, aged twenty-four, in whom a cyst had rapidly grown to the size of a pea ; then followed an arrack of acute glossitis, after which the cyst appeared, 246 DISEASES OF THE TONGUE. of the size of a nut, deep in the muscles of the tongue. Within a transparent cyst-wall was a cysticercus with a head, suckers, and a crown of hooklets. Echinococcus or Hydatid Cysts. A few observations are recorded of the occurrence of hydatid cysts in the tongue. Gosselin saw in a man, aged sixty-two, a cyst which had existed in the floor of the mouth for some time, pushing the tongue upwards and backwards, hindering deglutition and speech, and projecting somewhat under the chin. It was the size of a hen's egg, and, after treatment by puncture and by seton had failed, a cyst, lined by hydatid membrane and containing hooklets, was excised. Richet describes a hydatid cyst, the size of a lien's egg, situated between the geniohyoglossi and projecting into the mouth. Prechard saw, in a child aged seven, a tumour the size of a Tangerine orange which had taken eighteen months to grow. It projected into the mouth in the region of the tonsil, and on to the face in the parotid region. In Andre's case a boy of ten had a tumour below the jaw the size of an orange. On incision, hydatid fluid, membrane and hooklets were found, the cysts being situated within the capsule of the subm axillary gland. The treatment of hydatid cysts is very simple and successful. If the cyst is punctured and the hydatid sac turned out, recovery generally ensues. In most instances the sac escapes with the fluid when the cyst is opened ; but, if it does not escape, it can generally be easily shelled out. If the wall is degenerated and there seems to be a strong probability that suppuration will continue for a long time, the adventitious cyst should be dissected out. 5. Chronic Abscess. Chronic abscess may fairly be con- sidered in this place on account of some similarity which it presents to the diseases which have been just described. It has many of the characters of a cyst. It is perfectly circumscribed, lies just beneath the mucous membrane, which may be perfectly movable over it, and is smooth on the surface. Fluctuation may be perceptible it the pus is not too tightly packed ; and the little tumour is not usually painful or tender. Such a tumour may, therefore, easily CHRONIC ABSCESS. 247 be mistaken for a cyst ; but abscess is common in the dorsum of the tongue in front of the circumvallate papilla*, while mucous cysts are found behind the papillae; cysts are usually more prominent than abscess, and abscess is never translucent. It is very improbable that a chronic abscess should be mistaken for a carcinoma; yet the mistake has happened, when the abscess has ' been of small size, rather deeply situated, and yielding no sign of fluctuation. A chronic abscess of the tongue never attains a large size, and is in most instances not larger than a small nut. It may exist for years without even reaching the size of an ordinary nut. Its commencement is insidious, and very seldom is there any history of inflammation preceding the appearance of the tumour. It is an uncommon disease, and is met with more often in the tongues of adults than of children. It is almost always due to slight injury, and may sometimes be traced to a prick with a toothpick ; but it may be of tuberculous or syphilitic origin. The diagnosis has already been discussed, and it only remains to add that the presence of chronic . suppuration should always be suspected when there exists in the substance of the dorsal aspect of the tongue a small, circumscribed, smooth tumour, not very prominent, not translucent, not painful or tender, of long standing, rounded or ovoid. The diagnosis may be confirmed by an incision, and free incision with scraping generally serves for the cure of the disease. If the cavity fills again, owing to the thick wall of the abscess, excision will be necessary. CHAPTER XIV. DISEASES OF THE BASE OF THE TONGUE. THYREO- GLOSSAL CYSTS AND TUMOURS. Follicular Inflammation of the Lingual Tonsil Follicular Abscess of the Lingual Tonsil Hypertrophy of the Lingual Tonsil Varicose Veins at the Base of the Tongue Thyreoglossal Cysts and Tumours The Hyoid Bone: Injury, Necrosis, Tumours. IN Chapter I., p. 4 and p. 14, the anatomical considerations relating to the base of the tongue have been detailed. The affections to which the base of the tongue is liable group themselves into two divisions those connected with the lingual tonsil and the lymphadenoid tissue of which it is composed, and those connected with the thyreoglossal tract and the thyroid gland, of which it is an outlying part. 1. The Lingual Tonsil. Follicular Inflammation. Under the name of " lingual quinsy " Dr. David Craigie described, sixty years ago, an acute inflammation of the base of the tongue, apparently a very severe disease ; for one of the patients whom he saw died of it, and three or four patients recovered only after being exceedingly ill during the few days that the inflammation lasted. An acute glossitis, due to streptococcal infection, may attack especially the base of the tongue, and also there are rare cases, as has been mentioned, in which the base of the tongue is attacked by diphtheria. Lingual quinsy may be a severe form of acute tonsillitis, in which the inflammatory swelling is not so strictly limited as usual to the faucial tonsils, but extends to the base of the tongue and to the neighbouring parts, producing a considerable secondary swelling of the whole tongue. There is especial danger to life in such cases from laryngeal obstruction. But the follicular inflammation which occurs at the base of the tongue, although it is an altogether similar disease, may THE LINGUAL TONSIL. 249 exist without the faucial tonsils becoming involved. Whitish-yellow, hard concretions distend the crypts of the lymph follicles and project from the surface. These chiefly consist in an overgrowth of the corneous layers of the epidermis, which form concentric masses of shed epithelium distending the follicle: hence has arisen the term keratosis or hyperkeratosis. This affection is well described and illustrated by Kelly. The lingual tonsil is generally diseased alone, but may be attacked in common with, or secondary to, the faucial tonsils. The predisposing causes are anaemia and other conditions which impair health, such as badly ven- tilated rooms. Friedland noted the occurrence of folli- cular concretions in a number of medical post - mortems. Women who use the voice in singing, also clergymen, are said to be especially predis- posed. The symptoms vary according to the acuteness of the attack. Commonly they commence with pain in swallowing, aching, irritability, and cough. In the laryngeal mirror one or more follicles (Fig. 16) are observed to be swollen and projecting with masses in the centre, or the concretions in several follicles may be joined by bridges of whitish-yellow material. The concretions are firmly adherent in the follicles, from which they are scooped out with difficulty. The concretions are found to be com- posed of squamous epithelial cells with leptothrix threads. The tendency of the symptoms is to subside, and then to recur, especially when the patient is exhausted or uses the voice excessively. The general treatment of follicular inflammation consists in adopting measures which will tend to improve the patient's health, and in the removal of causes of irritation, such as tobacco smoke. But in order to cure the patient the follicles must be cleared out, or the lingual tonsil removed.* * Although I have seen a large numher of tongue and throat cases, I have Fig. 16. DRAWING OF A SWOLLEN LINGUAL TONSIL AS SEEN BY THK LARYXGOSCOPIC MIRROR. 250 DISEASES OF THE TONGUE. Follicular Abscess A follicular inflammation may run an acute course with marked pain and difficulty in swal- lowing, and, if the mouth of the follicle remains closed, an abscess forms. The symptoms are practically similar to ordi- nary acute tonsillitis without the faucial tonsils and pillars being swollen (\Vetmore). The abscess is small and cir- cumscribed, containing the staphylococcus pyogenes in the pus. It may burst, and relief follows ; then, upon examina- tion, a sinus will be found, into which a probe can be passed. When the abscess is situated on one side there is a corre- sponding sAvelling of the tongue, a hemiglossitis, which is the more marked when the faucial tonsil and pillars of that side are also involved, as in the case described by Knight. An abscess in this position may only come into view when the patient is examined by the laryngeal mirror, or it may be touched by the finger, or, if large, seen when the mouth is opened. The abscess may be incised with a curved, pointed, guarded bistoury, guided by the finger. The patient should be sitting up with the head hanging forward, or lying on one side with the head low. The better plan is to open the abscess under the guidance of the mirror to avoid wounding super- ficial veins. After painting with cocaine, the abscess is first punctured so that pus shall not at once flood the patient's pharynx. When he Jias cleared his throat, a free incision is made, and the cavity wiped out or curetted. Hypertrophy of the Lingual Tonsil. The lingual tonsil may become permanently hypertrophied (Fig. 15), and may require removal. This is best accomplished by means of a hot wire loop or by punctures with the electric cautery. Lymphosarcoma (see Sarcoma of the Tongue, Chapter XVIL). Varicose Veins at the back of the Tongue. So much has been written on this subject during the last ten or more years that it cannot be passed over in silence. At least twelve different symptoms have been attributed to this condition, amongst them pain at the back of the tongue, hoarseness, seen very few cases indeed of affection of the lingual tonsil, and still fewer which required active treatment. I have come to the conclusion that the importance of the subject has been somewhat exaggerated.- -H. T. B. THYREOGLOSSAL TUMOURS. 251 irritability, dysphagia. Our experience has led us to believe that there is really no condition of the veins at the base of the tongue which merits to be called varicose. Any person who looks at these veins for the first time with the laryngeal mirror in a healthy person will be struck by their large size and the quantity of blood they appear to contain. The Minptoms which have been associated with enlargement of the veins are such as are very common in neurotic subjects. We have never applied the cautery to these so-called varicose veins, nor do we think we are likely to do so. 2. Thyreoglossal Cysts and Tumours. As already mentioned in Chapter I., the researches of His made on very young human embryos have enabled this tract (there is no sign of any duct) extending from the foramen csecimi to the pyramidal lobe of the thyroid gland to be fully traced. It has proved of the greatest service in explaining the occurrence of the cysts and tumours now to be described (Fig. 2, p. 5). (a) Tkyreoylossal Cysts and Tumours on the Dorsum of tin- Tongue in the Position of the Foramen Caecum. Cases have been put on record of which the pathology can now be explained. Thus, Hickman in 1868-9 described a congenital tumour of the tongue extending from the circumvallate papilla 1 nearly to the epiglottis, and deeply into the tongue, which caused death by suffocation sixteen hours alter birth. The infant's tongue, with the tumour, is preserved in the College of Surgeons' Museum (No. 2271). The Morbid Growths Committee of the Pathological Society at that date described the tumour as consisting of hypertrophy of race- mose glandular structures with connective tissue and blood vessels. In 1883 Bryant described a cyst of the base of the tongue reaching forwards to the circumvallate papillae, which had existed for four or five months in a girl of eighteen. During the previous ten days the patient had bled to a considerable amount from the nose and mouth. The cyst was incised and plugged, and healing followed. Butlin described in 1890 two cases of tumour in the position of the foramen crecum, and gave drawings of the microscopical sections, which are here re- produced (Fig. 17). They would formerly have been described 252 DISEASES OF THE TONGUE. as adenomata ; but, in accordance with the views expressed by Bernays and Bland-Sutton, opinion was expressed that they consisted of thyroid gland tissue. On looking at the microscopical sections again, the thyroid nature of the tumours is, if anything, more evident than in the drawings. Cysts may occur in connection with these tumours. And in some cases the entire tumour appears to be composed of a single cyst. But a careful microscopical examination shows that the cyst is lined with ciliated epithelium, and that there is thyroid gland .../ tissue in its wall, which is extremely vascular. This gives rise to a character- ,v'vr"v istic feature of these cysts, the liability to recurrent attacks of haemorrhage, causing a sudden enlarge- ment if the wall remains intact, or free haemorrhage into the mouth when the Fig. 17. THYKEOGLOSSAL TUMOUR. Cyst wall is ruptured. Drawing reproduced from Butlin's paper. The Although often not larger Microscopic Sections are in St. Bartholomew's , 1 Hospital Museum. than a pea, the cyst may increase to the size of a cherry or more. Johnson described a congenital cyst of the tongue, lying between the circurnvallate papillae and the epiglottis, lined by several layers of flattened epithelium, which caused such dyspnrea that tracheotomy had to be performed when the child was aged four months, and death ensued one week later. So vascular are the tumours that simple puncture of the swelling has caused a pint of blood to be lost, and the recurrent haemorrhage may render the patient anaemic. It is this tendency to haemorrhage which brings about sudden changes in the size of the tumour. The tumours are situated in the position of the foramen csecum ; but, if large, they tend backwards towards the epiglottis. They are generally sessile, varying in size from a cherry to a hen's egg. They appear well defined, but on palpation a solid and a cystic tumour THYROID GLAND AND THYROID TUMOURS. 253 resemble each other. They cause no projection beneath the chin, although there may be a second tumour just above the hvoid bone. The surface is covered by the normal stratified epithelium, and the colour is variably described as bluish- brown or dark red. Owing to its vascularity, this colour is readily changed by haemorrhages. The tumour is enclosed in a distinct capsule with septa, and appears on section of a brown or reddish colour, and small cysts are seen from which colloid matter can be squeezed ; and if the cyst is large, the fluid may contain blood or clot. Under the microscope there is to be seen typical thyroid gland tissue, spaces lined by cubical epithelium, and containing colloid matter, with or without a cyst in the centre of the tumour lined by ciliated epithelium. Besides this, parts of the tumour may present embryonic thyroid tissue or spherical nodules similar to thyroid adenomata. These cysts are more commonly met with in young patients just before or about puberty, but they muy be seen at the extremes of life. The tumour may be congenital, but has been seen in patients aged tifty-two and seventy-seven. The affection is much commoner in women. An abnormal condition of the thyroid gland itself often exists along with a thyroid tumour. In particular, the gland may be ill-developed or absent, and the tumour upon the dorsum of the tongue has been proved to have been physiologically an active thyroid gland in that its removal has produced in the patient operative myxcedema or cachexia strumipriva. Chamisso de Boncourt described the case of a cretin, aged thirty-seven, who appeared like a girl of ten. She had a tumour in the position of the foramen caecum which impaired speech, -deglutition, and respiration. The tumour was of the size of a walnut, and was removed through the mouth after tracheotomy, when it was found to consist of thyroid tissue. No thyroid gland could be felt. Six months afterwards no signs of recurrence had appeared ; but there was swelling of the eyelids, of the root of the nose, slight O3dema of the back of the hand, and marked swelling of the lower part of the leg and foot. Thyroidin treatment was therefore adopted. Seldowitch removed a tumour the size of a cherry from the base of the tongue of a girl, aged fourteen, with the galvano- 25 I DISEASES OF THE TONG !'!:. cautery. He found that the tumour consisted of thyroid tissue. Seven months later the patient was seen again with well-marked myxcedema, including intellectual changes. No thyroid gland could be felt in the neck. Treatment with thyroidin completely cured the patient, A man, aged twenty-five, had spoken since childhood as if he had a lump in his mouth, arid for three years there had been repeated haemorrhages. A tumour was removed from the base of the tongue in the position of the foramen caecum by Reintjes after tracheotomy and the division of the palatoglossal folds. The tumour consisted of normal thyroid tissue. There was no sign of a thyroid gland in the neck, and after the operation the patient developed my x oedema. The thyroid gland may be, however, perfectly healthy. It may feel normal, the isthmus has been exposed during the tracheotomy operation and has been found normal, also no disturbance has followed upon removal of the lingual tumour. In some cases a thyroid tumour on the dorsum of the tongue has been accompanied by one in the region of the hyoid bone. In Bernays' case one tumour projected from the base of the tongue into the pharynx, and another was found above the hyoid bone in the middle line. In the case described by Galisch a thyroid tumour had been excised from the middle line, just above the hyoid bone, a year before a similar tumour developed on the dorsum of the tongue. Diagnosis of Tkyreoglossal Cysts and Tumours in tlte region of the Foramen Ccecum. As a summary of the features already noted, the cyst or tumour, if small, is exactly in the position of the foramen. It may pass unnoticed or slowly enlarge and cause slight difficulty in speech and deglutition ; but if large it extends back towards the pharynx and presses on the epiglottis. It is of slow growth, and is not attended by any glandular enlargement, although it may be accompanied by a tumour in the region of the hyoid bone. The thyroid gland may be normal or not felt. It may cause recurrent haemorrhage from the pharynx with no, or only slight, provocation, which has the character of free oozing and produces amemia, but is TREATMENT OF THYItEOGLOSSAL TUMOURS. 255 not accompanied by fixation of the tongue or foul breath. On inspection, a brown or reddish projection is seen, from the size of a pea to that of a cherry or walnut, exceptionally to the size of an egg, sessile, not pedunculated, covered by normal epithelium. Over it course largish veins, between which paler, glistening protrusions of small cysts may be seen. To the touch the tumour feels soft and circumscribed, without any sign of induration. It is usually so soft that the finger cannot distinguish between a cystic and a solid tumour. The chief importance in the diagnosis is to distinguish it from a malignant tumour, lest an operation in excess of the requirements of the case be carried out. The absence of ulceration, of induration and of glandular enlargement, together with the length of time the symptoms have lasted, and the early age of the patient, who is often a woman, all negative the idea of cancer, which the recurrent haemor- rhages might suggest. Treatment. Supposing a cyst or tumour of small size to be found by chance, which has not caused symptoms, there is no indication for treatment. No case has been described where such tumours have become the seat of malignant disease. If the symptoms are slight, due to a temporary con- gestion, the administration of iodides and the application of an astringent paint . may suffice to permanently relieve the patient. The tumour may be really a supplementary thyroid gland ; indeed, as the cases show, it may be the most active portion of the gland. The simple presence of a tumour, therefore, is not a sufficient indication for an operation. But an operation is indicated when speech and deglutition are progressively impaired, when there is a continuous cough, pain, etc., and especially when the tumour begins to impede respira- tion, and to occasion recurrent haemorrhages. The simplest form of operative treatment is carried out under cocaine, guided by the laryngeal mirror. The pro- jecting tumour is snared by the galvano-cautery wire or burnt down level. Care should be taken not to set up hemorrhage by using the cautery too hot, or by working too quickly. The tumour should not be punctured, or incised, 256 DISEASES OF THE TOXCI'I-:. or torn off with the cold snare, otherwise free haemorrhage may take place, which will be difficult to control with the patient awake. This plan removes only the projecting tumour, yet this may suffice, especially when a thyroid gland cannot be felt. The relation of one of Butlin's cases shows this, and also Rushton Parker's case, which is mentioned in the paper. Threatened recurrence of the growth in each instance was followed later by subsidence. The more thorough method is to operate under chloro- form, with the head hanging low, the mouth well gagged, open, and the tongue drawn forwards. The tumour can be outlined by incising the epithelium around it, and can then be shelled out. The cautery may be used for cutting round the tumour if the veins are large. Bleeding is arrested by sponge pressure, by ligaturing any bleeding point, or by touching with the cautery. The edges of the wound may be drawn together by sutures. If the bleeding is care- fully arrested, and the after-treatment directed towards keeping the healing surface healthy and protecting it from being rubbed by solid food until it is healed, there will be no danger of secondary haemorrhage. A preliminary tracheotomy is unnecessary, except when the patient cannot breathe easily under the anaesthetic. There is no danger of blood getting into the larynx if the operation is done as described. A submaxillary operation is an excessive procedure for a tumour at the foramen caecum. It should be undertaken only when a tumour about the hyoid bone has extended upwards secondarily. (b) Thyreoylossal Cysts and Tumours in the region of the Hyoid Bone. Streckeisen in 1880 made a number of post- mortem examinations with respect to the presence of accessory or supplementary thyroid gland masses in the neighbourhood of the hyoid bone. This was in Basle, where the patients lived in a region where diseases of the thyroid gland are endemic : hence, perhaps, a greater prominence of accessory thyroid bodies. This may explain the negative results arrived at by Kanthack, who worked in Berlin and in this country. Streckeisen divided these accessory thyroids as follows: (1) Glanduhe pnehyoidea? lying in front of the mylo- THYREOGLOSSAL G'FNV> AltOI'T H VOID BONE. 257 hyoid muscle and the hyoid bone, covered only by cervical fascia. The masses may be distinct or connected with the pyramidal lobe below or with the suprahyoid gland masses above through the mylohyoid muscle. The connection may be glandular, fibrous, or simply vascular. (2) Glandulae suprahyoidea- found as small nodules just above the attach- ment of the mylohyoid muscle, sometimes covering the anterior surface of the hyoid bone, and intimately connected with the periosteum, which may form a sort of capsule for the gland masses. The connection with the pyramidal lobe through the mylohyoid may be intimate. The structure of these thyroid follicles may be normal in appearance, but generally they are ill-developed, without lumen, consisting merely of epithelial strands. (3) Glandulu' epihyoidese. From the upper border of the hyoid bone there extends upwards between the geniohyoglossi muscles towards the foramen ca?cum a strand of tissue which shows thyroid gland, follicles, and colloid granules. (4) Glanduhe intrahyoidea?. Glandular masses of thyroid tissue are either developed and included in the body of the bone during the period of ossification, or they grow into the bone from the outside and become embedded, especially the portion of the suprahyoid gland intimately connected with the periosteum. In the hyoid bone were found thyroid alveoli of considerable size communicating with one another, and lined by cubical epithelium. Streckeisen also found mucous cysts lined by ciliated epithelium connected with all these sets of glands. A better knowledge of this thyreoglossal tract, with its accessory thyroid glands, tumours, and cysts, leads to more correct operations. Surgeons have erred in the past by excess, the tumours having been mistaken for malignant ones; or cysts have been simply punctured, injected, or partially removed, leaving a troublesome fistula in the neck which has lasted for years and resisted repeated operations. Thyroid tumours and cysts, when they occur above the hyoid bone and mylohyoid muscle, tend to project at first between the chin and the hyoid bone, then they push upwards and backwards the base of the tongue, causing difficulty in speech, swallowing, and ultimately in respiration (see Diagram, Fig. 15, p. 241), and when they project in the 258 DISEASES OF THE TONGUE. region of the foramen crecum, give rise to recurrent haemor- rhages. They are situated in the middle line, and may be con- founded with the epidermal or dermoid cysts, but feel softer. The distinction is unimportant, however, as the treatment is the same. A girl of eighteen had a tumour in this position, which grew until tracheotomy became necessary. Wolff divided the lower jaw and split the tongue, after ligaturing both linguals. A tumour the size of a walnut was removed from the middle line of the tongue beneath the mucous mem- brane, and was found to be composed of thyroid tissue. The case described by Galisch is of especial interest, owing to the secondary extension of the growth to the base of the tongue. A woman, aged twenty-four, had a tumour the size of a hazel- nut between the chin and the hyoid bone. It was removed through a transverse skin incision, which healed after three weeks, leaving a scar seven centimetres in length. She remained well for a year, when suddenly, at dinner, she felt a sharp pain, had an attack of coughing, and brought up a quarter of a litre of dark blood. She felt rather faint, but the bleeding stopped, and she went on with her work. Two hours later, after again taking food, and immediately after swallowing, she felt an obstruction in the throat, and brought up half a litre of blood. Then she had borborygmi and retching, and brought up one and a half litre. Whilst being taken to the hospital she again brought up a third of a litre. In bed the patient felt something warm rising up. She sat up, without cough or retching, and let the blood flow in a stream out of her mouth into the spit-cup. Bleeding recurred for a day or two, then the patient mended slowly. After a month she sat up. At the end of six weeks a complete laryngoscopic examination was made, and a tumour the size of a cherry discovered behind the circumvallate papilla?, hiding the epiglottis. The tumour was punctured, causing sharp haemorrhage, amounting to 400 cc., which was stopped by ice. After low tracheotomy, during which a normal thyroid isthmus was exposed, a T-shaped skin incision was made, the tongue split, and the hyoid bone divided in the middle line. A tumour was in this way exposed measuring 2 - 5 to 3 cm. in diameter, which projected on to the surface of the tongue, encroached at the sides on EXCISION OF CYSTS ABOUT HYOID BONE. 259 the geniohyoglossi and the fauces, and at the hinder part upon the epiglottis. The tumour was cut out with the knife, and there was free hemorrhage, as is usual in goitre operations. Some deep lingual vessels were tied. The wound was closed by suture in stages. The patient swallowed the next day; the tracheotomy tube was removed on the third day. The patient slowly recovered from the ansmia, and was seen six years later quite well. The tumour was composed of thyroid gland tissue. The case just described represents the full operation which may be required. But granted the existence of a tumour in the middle line of the tongue between the chin and hyoid bone, a median skin incision should be made and the muscles carefully separated until the tumour is reached. It may be found that there is a dermoid cyst which easily shells out ; a thyroid cyst or tumour may do this also owing to the well-defined nature of its capsule, and then this small median incision Avill suffice. The freer T-shaped incision will be required when the tumour is large and its wall friable and vascular. There is no need to make a preliminary ligature of the lingual arteries, as if the tumour is first of all well exposed and carefully shelled or dissected out, only hyoid and dorsal branches of the lingual will be injured. The hypoglossal nerves must be carefully avoided. A preliminary tracheotomy will not be necessary except when the tumour pushes up the base of the tongue and the patient cannot breathe easily under the ancesthetic. The hyoid bone may be divided (see below), but there is no need to cut through the lower jaw. Below the mylohyoid cysts and tumours are frequently seen in young adults, both women and men. When first noticed they may be of the size of a pea, but may grow gradually larger if not removed. Thus, they have been seen of the size of a mandarin orange (Liaras). Perhaps the ex- treme limit was reached by the case described by Waterhouse, which had existed for thirty years. The cyst reached from the lower jaw to the clavicle. It bulged into the mouth so that it seemed almost to divide the tongue into two, extend- ing up to the mucous membrane. The cyst was firmly adherent to the hyoid bone and to the thyroid isthmus, and 260 DISEASES OF THE TONGUE. contained two pints of fluid. These cysts and tumours have been frequently punctured or injected with iodine, or have spontaneously ruptured, leaving a fistula opening into the neck, which continues to discharge a glairy fluid, especially when the patient is at meals, and this may go on for years. There is ample evidence, from microscopical examination, afforded by the papers of Durham and others, that these cysts are lined with ciliated epithelium or arise secondarily in thyroid tumours. Even when a fistula has existed some time and much of it is lined by granulation tissue, yet remains of ciliated epithelium and thy- roid gland tissue may be found. These cysts and tumours are continuous Avith the pyramidal lobe and isthmus of the thyroid below and with the hyoid bone above. They are covered by the deep fascia and the septum of the sternohyoid muscles, and lie on the thyrohyoid ligament, from which they are quite separate. They do not in any way involve the thyrohyoid ligament, except by bulging it inwards upon the epiglottis and the larynx. These tumours and cysts cannot be confused with any- thing else, lying as they do either in the middle line or just to one side between the thyroid isthmus and the hyoid bone. There are no lymphatic glands in this region. Sebaceous cysts involve only the skin, but a dermoid cyst lined by stratified epithelium may occur in the same position. It is treated in the same way and will shell out easily. An enlargement of the bursa described by anatomists as existing between the hyoid and thyroid cartilage has been given as an explanation of the occurrence of these cysts. Such an enlargement should contain serous or synovial fluid, with fibrinous bodies like poppy seeds, rice grains, or melon seeds, with a wall lined by flattened epithelium and composed Fig. 18. CILIATED EPITHELIUM FEOM A THYBEOGLOSSAL CYST. Copied by the kind permission of Dr. H. Durham, from his paper. FISTUL/E ABOUT HYOID HONE. 261 of fibrous tissue. This has never been demonstrated. One cannot deny the possibility of the occurrence, but the statements with regard to this supposed distension of the thyrohyoid bursa are purely traditional. It will be enough to note that it must be quite an exceptional condition, and it can be only accepted as occurring when it shall have been demonstrated. Meanwhile, statements about thyrohyoid bursae may be ignored. If acute inflammation be set up in one of these cysts or tumours some contusion may arise, and the case may for the moment be diagnosed as syphilitic or tuberculous disease of the thyroid cartilage, but when the inflammation has subsided a fistula will be left discharging glairy fluid. The close connection of such cysts to the hyoid bone may be noted during post-mortem examinations or ana- tomical dissections. In the College of Surgeons' Museum, specimen No. 232 A, is a thin- walled cyst overlying the thyroid cartilage and thyrohyoid ligament, and extending up behind the hyoid bone, taken from a dissecting-room subject. Specimen 232 is a dried specimen of the hyoid bone with a round thick-walled cyst more than two inches in diameter. The specimen was obtained from Liston's museum, and was taken from a sailor between fifty and sixty, in whom the cyst had existed nearly as long as he could remember. The cyst was covered by the sternohyoid muscles, loosely connected with the surrounding soft parts, and attached to the posterior surface of the hyoid bone. The cyst was full of brownish-yellow, thick, grumous, honey- like fluid containing cholesterin crystals. (This is not the contents of an enlarged bursa.) Treatment. A cyst or tumour must be carefully excised with the patient under a general anaesthetic. Any strand leading up to the hyoid bone or towards the thyroid isthmus must also be followed up. Attempts to do this without an anaesthetic, b}^ freezing or by cocaine infiltration, etc., will probably fail. Puncture and injection methods are quite wrong, and produce fistulae. Fistulse are much more difficult to excise than the uncomplicated cyst or tumour, yet this may be successfully accomplished, as shown by the cases described by Durham and others. 262 DISEASES OF THE TONGUE. In particular, it is necessary to remove the wall of the cyst or fistula when it is adherent to the posterior surface of the hyoid. Generally, a division of the bone is not required. Exceptionally, it is needed when the bone itself is actually involved, and no evil consequences follow from the division. Schlange operated upon a man, aged twenty, who had a fistulous opening in front of the thyroid cartilage ; the upper end of the fistula was continuous with a tumour the size of a cherry firmly attached to the periosteum of the hyoid. The middle of the hyoid bone was resected, when another tumour of similar size was found attached to the periosteum of the posterior and upper surface, from which a gradually diminishing extension of the tumour was followed up to the base of the tongue. The tumour consisted of many-branched alveoli, lined by columnar ciliated epithelium embedded in fibrous tissue. Beck also divided the hyoid bone to cure a fistula extending up behind. Not the slightest difficulty followed with deglutition or speech. A division of the hyoid bone may be adopted therefore without hesi- tation if it is found necessary in order to cure the patient. Some other conditions involving the hyoid bone may be briefly referred to. 3. The Hyoid Bone. Fracture of the Hyoid Bone. This may be caused by a garotter, by a blow, or by a bullet (Uhlmann). There is danger of simultaneous injury to neighbouring vessels, also the larynx may be involved, or rederna glottidis may set in requiring tracheotomy. Displacement may be rectified by a finger in the pharynx, after which measures must be taken to avoid septic infection. Dislocation of the Hyoid Bone. Wood has described a partial dislocation of the hyoid occurring during cough in phthisical patients with tuberculosis of the larynx. One cornu appeared tilted up and fixed. The displacement was reduced by holding the bone with the thumb and finger, and telling the patient to swallow. Tuberculous Caries. Uhlmann removed a carious hyoid bone from a man, aged twenty-eight. No disturbance followed, and the wound healed. The caries is generally secondary to laryngeal tuberculosis. TUMOURS OF HYOID BONE. 263 Pycemw Abscess. Uhlmann also mentions Stetten's case, in which a pysemic periosteal abscess followed otitis media purulenta. Syphilitic Nodes and Gummata. Elliot mentions six cases in whom there were tenderness and thickening of the hyoid bone without any laryngeal or pharyngeal affection, which disappeared on administering iodides. Amongst them were two women suffering from periosteal nodes in common situations. Le Dentu also describes a tumour of the hyoid bone in a woman, aged seventy-one, which may perhaps have been a gumma. Tumours of the Hyoid Bone. Fibro-cartilaginous tumours, perhaps having a branchial origin, have been found attached to the great cornu of the hyoid bone. Anderodias and Hugon found in a child, aged five months, a nipple-like appendage composed of fatty and fibromatous material with cartilage. Bo3ckel described, in 1862, a cystic fibro-chondromatous tumour intimately united with the great cornu. It had been noticed for three years in a woman, aged fifty, and had reached the size of two fists. The tumour was removed with the great cornu, but secondary haemorrhage followed from the external, and then from the common carotid, and the patient died on the seventh day. Spisharny's case showed a tumour the size of a hen's egg, closely connected with the right cornu, with which it moved. The great cornu was cut across, and then the encapsuled tumour easily shelled out. It was composed of fibrous tissue and cartilage with numerous cells. 264 CHAPTER XV. HYPERTROPHY OF THE TONGUE, OR MACROGLOSSIA. Lymphangiomatous Macroglossia, including Lymphangioma Simple Muscular Macroglossia Inflammatory Hypertrophy. OTHER names used are elephantiasis and lymphangioma ; those now rarely used are prolapsus linguae, lingua vituli, lingua propendula, lymphadenoma cavernosura. Three forms of hypertrophy of the tongue can be recognised (1) Macroglossia from dilatation of lymphatic spaces, the lymphangiomatous form, including lymphangioma. (2) Simple muscular hypertrophy, generally accompany- ing a defective intellect or general or unilateral hypertrophy. (3) Secondary hypertrophy of inflammatory origin. 1. Lymphangiomatous Macroglossia, including Lymph- angioma. This is the typical form of macroglossia, and the essential feature of its pathology is the dilatation of lymphatic spaces, with which the disease commences, as was first of all clearly demonstrated by Yirchow. This dilatation must be due to the outflow of lymph being prevented, whether by the efferent lymphatics not being formed or being subsequently obstructed. That the efferent lymphatics may be so ill-formed that they do not become patent channels seems most probable, seeing that the disease is often congenital, and may coincide with hygroma in the neck. The enlarged condition of the tongue has been noted at birth so large, indeed, as to prevent breathing, or to shortly cause death. It is not necessary for the congenital origin that the whole tongue should be enlarged at birth ; only part has been enlarged, or a patch has been noticed, and subsequently diagnosed as a lymphangioma, or lymphatic noevus. This, after remaining quiescent for a variable length of time, even LYMPHANGIOMATOUV MACROGLOSSIA. 265 until puberty, may then commence to enlarge. Even in those cases in which no enlargement or lymphangioma has been noticed at birth, it seems most likely that the rnacroglossia, which appears later, has had its origin by extension from some dilated spaces buried in the substance of the tongue. The cases which tell against the invariable congenital origin of lymphangiomatous macroglossia are those in which macroglossia has followed injury. In Dolliriger's case of macroglossia in a man aged twenty-one, the disease had commenced after division of the framum at the age of two. In Sedillot's case of macroglossia in a boy, aged nine, the framum had been divided at five, after which the swelling commenced. Macroglossia has also set in after operations upon the lower jaw (Girerd). In very many cases it has been made much worse by the inflammation set up by the methods of treatment. The pathology of macroglossia has been the subject of much dispute owing to the differences which exist between cases examined in an advanced stage. But if the simplest form of lymphangioma is considered first of all, the different changes which later on occur can be explained (see the list of references). Lymphangioma, or lymphatic nceviis, appears on the surface of the tongue as a group of vesicles which have transparent walls with clear serous fluid. Between the vesicles are bright red points made by capillary loops (Plate \ 7 II., Fig. 2). If a vesicle ruptures, clear fluid escapes. If a capillary ruptures into a vesicle, it becomes distended with blood, causing the distended vesicle to assume a bluish-black appearance. The lymphangioma may be a very small patch, or cover a considerable portion of the tongue, or form a sort of crest like a coxcomb. It may project from the surface or extend deeply into the sub- stance of the tongue. Instead of being grouped in a patch, vesicles like millet seeds may be scattered widely on the dorsum, some white containing lymph, others red from arterial blood, others violet from venous blood. If a vertical section be made of a simple lymphangioma, the lymphatic, spaces immediately beneath the epithelium are dilated ; by further enlargement the lymph space bulges towards the surface, thinning the epithelium by pressure 266 DISEASES OF THE TONGUE. until only a layer of corneous epithelium covers the surface. The contents of the space are lymph, serous fluid containing numerous Avhite corpuscles (Fig. 20). By extension between the muscular fibres and fusion of the lymph spaces large cysts are formed, so that the portion of the substance of the tongue invaded has a honeycombed * Fig. 19. MACROGLOSSIA HYPERTROPHY OF EPITHELIUM AND SCLEROSIS OF MUSCLE. look (Fig. 21). Around these dilated lymphatic spaces three changes take place, and it is in accordance with the relative proportions in which each occurs that the differences found in advanced cases are due. These are (a) : dilatation and new formation of blood vessels, (h) inflammatory changes with formation of fibrous tissue, (c) new growth of lymphadeno- matous tissue. (a) The capillary loops between the vesicles in the simple form develop into arteries, thin-walled, coiled, and of a considerable size. The veins also increase in number and become dilated. Then the blood vessels rupture into the * Photographed from recently made sections taken from specimens kindly sent us by Mr. A. G. Francis, and which will he placed in St. Bartholomew's Hospital Museum (see his Paper). Pig. 19 shows the overgrowth of the epithelium, the elongation of the papilla- , and the replacement of muscular fibres by tough fibrous tissue. MACROGLOSSIA AND LYMPH ANGIECTASIS. 267 * Fig. 20. MACROGLOSSIA SUPERFICIAL LYMPH CYST. * Fig. 21. MACROGLOSSIA DILATED LYMPH SPACES AND LYMPHADENOMATOUS TISSUE REPLACING MUSCLE. * Photographed from recently mar,1. T. has noticed that the alveoli of the teeth are ill-formed, owing to disuse, as the jaws cannot be closed. It must not be imagined that macroglossia runs a rapid course, or that the effects which have been just described are produced in a few weeks or even months. It is a very chronic malady, slowly advancing during months and years, sometimes stationary for long periods, then quickly enlarging after an attack of inflammation ; sometimes steadily, though very slowly, advancing. The worst effects are seldom seen until several years have elapsed. After slowly increasing during many months or years, the tongue may become stationary and cease to grow ; but we are not aware of any instance of a well-marked example of this disease diminishing and undergoing spontaneous resolution. Some of the complicating features of macroglossia have been probably of artificial production. The swelling of the gums, the coating of the teeth with tartar, the loosening and falling out of the teeth, the foul breath, the ulceration and 272 DISEASES OF THE TONGUE. subsequent adhesions to the cheek or gums, as described in some of the cases, were very likely produced by the mercury, which was either given internally or applied freely to the tongue. Ulceration and sloughing, with septic complications, also followed the leeching and scarifications formerly in vogue. The drying and fissuring of the surface have often been prevented by the patients themselves covering up the exposed tongue, keeping it in a sort of bag. Another com- plication is ulceration under the tongue, set up by the edges of the teeth, and leading to small haemorrhages from the ranine veins. Virchow has likened this disease in some respects to elephantiasis (congenital and acquired), and the analogy seems just when the lymphatic relations of the two diseases are considered. In both there is dilatation of lymphatic vessels and connective-tissue hypertrophy ; in both the affection seems capable of being excited or aggravated by attacks of inflammation. In a few cases there has been actual proof of disease of the lymphatics in parts neighbouring to the tongue. Thus, Virchow tells of a little girl, two years old, under the care of Von Tex tor, who, Avith niacroglossia, had an enlarged (?) gland beneath the jaw containing clear lymph. And Maguire describes the case of a girl of the same age whose macro- glossia was associated with a cystic hygroma on both sides of the neck. In this case, the death of the child afforded an opportunity of examining the disease, both of the tongue and of the neck. Valenta .has recorded a somewhat similar case. In Winiwarter's case there was congenital niacroglossia, accompanied by a congenital hygroma in the neck. Brault's patient had niacroglossia with lymphangiectasis of the floor of the mouth and of the cervico-facial region. Tenneson's patient was a man, aged twenty-three, in whom the niacro- glossia had been first noticed when he was four months old. He had a venous nsevus of the lower lip; also one in the neck at the level of the hyoid bone, as well as a capillary nsevus on the ear. In one of the cases (case vi.) described by Maas there was a venous n;evus of the lip and tongue, and enlargement followed. The theory of lymphatic obstruction makes it more easy PLATE VIII. Fig. 1. Warty cancerous growth of the tongue of an old man, which had been leucomatous for many years. The warty growth had not heen noticed longer than a few weeks. Fig. 2. Protuberant carcinoma of the tongue of a man, with a slough of the central part. Fig. 3. Ulcerated and fissured carcinoma in a man, aged 52, under the care of Mr. T. Smith. The tongue lies within the opened mouth, and cannot be protruded. PATHOLOGY OF LYMPHANGIOMA. tl73 to understand the relation between macroglossia and such apparently trivial causes of the disease as ranula, abscess, and other affections producing swelling of the floor of the mouth. They tend to produce obstruction to the return of lymph from the tongue, and thus to induce the sequence of events which leads to macroglossia. In reference to the observation of Virchow, already alluded to, regarding the analogy of this disease to elephantiasis, it is worthy of remark, however, that in those countries in which elephantiasis is of frequent occurrence macroglossia does not seem to have been simultaneously observed. Fayrer especially remarks, in his observations on a case of macroglossia which he had seen in a Bengal Brahmin, that this was the only case of the kind he had noted in India. Granted that the lymphatic obstruction is generally of congenital origin, there is as yet no answer to the question why the disease tends to spread to the whole of the tongue. Hutchinson has termed it "infective lymphangioma," and compared it to lupus lymphaticus of the skin. Mikulicz seems to regard lymphangioma as a new formation of lyinph vessels, which dilate into spaces. In his Atlas (Tafel xxviii., Fig. 3), there is depicted a sublingual nodular lymphangioma on the right side of the fnenum underneath the tongue, forming a tumour the size of a cherry. The patient was a man, aged forty, who had had frequent attacks of inflam- mation and suppuration, for the relief of which subrnaxillary incisions and also tracheotomy had been necessary. Then there was a period of quiescence for some years, and finally the tumour was removed by the cautery. But this is not the course of a new growth, and lymphangioma and macro- glossia are very different affections from the endotheliomata which arise from the endothelium lining lymphatic spaces. The analogy with elephantiasis, as pointed out by Virchow, still seems the most likely explanation, and some form of micro-organism is probably the cause of the spreading of the lymphangiomatous change. In Brault's case, in which there was macroglossia with lymphangiectasis of the floor of the mouth and of the cervico-facial region, the recurrent attacks of inflammation coincided with teething, and pneu- mococci were found in the cysts. He believed that the s 274 DISEASES OF THE TONGUE. organisms got in from the mouth, and set up the inflam- mation. Bacteriological observations on the contents of unaltered lymph cysts may throw further light upon the pathology of lymphangiomatous macroglossia. Ribbert would draw a distinction between the non-circum- scribed dilatation of existing lymphatics and a lymphangioma proper of congenital embryonal tissue forming a circum- scribed tumour. But this distinction is practically a difficult one to draw, the lymphangioma continuing to spread, although at a slow rate, so long as it is not, or is only partially, removed. The diagnosis of lymphangiomatous macroglossia is made by the presence of cysts of varying size in connection with a chronic progressive enlargement of the tongue. The lymphangioma may vary from a small clump of vesicles, a broad patch of vesicles with large blood vessels and blood cysts, to vesicles scattered widely over the tongue, or a multi- locular cystic tumour beneath the tongue. The presence of some clear vesicles, and the tendency to spread, however slowly, even if there are dilated capillaries and large blood spaces, will distinguish a lymphangioma from a simple angioma or nsevus. Treatment. There is only one treatment for lymphangioma and lymphangiomatous macroglossia, wedge-shaped excision. The older methods by puncturing, injecting, applying pres- sure by strapping, incisions, blistering, leeching, use of setons, treatment by mercury or iodide of potassium internally and externally, are calculated only to make the disease worse. The same is the case with caustics and the cautery, which may destroy cysts on the surface, whilst they promote extension in the muscular substance by setting up inflam- mation. Generally speaking, the operation should not be post- poned, the local lymphangioma should be cut out freely, or as much of the enlarged and projecting part of the tongue cut away as necessary, and then the edges of the wedge- shaped incision united by suture. The operation may prove fatal from the extreme youth of the patient, as in the case mentioned by Francis. If, however, the infant cannot take food properly and is liable TREATMENT OF MACROGLOSSIA. 275 to attacks of dyspnoea, the operation, carried out with all care, will give the little patient the best chance of living Unless the case is neglected until puberty, no secondary deformity of the jaw or of the lip need arise. (Compare the cases of Siebold, Fig. 23, p. 271, and Mirault.) If the disease is not far advanced, and the operation can be postponed until the child is stronger and older, nothing should be done to irritate the tongue or to cause extravasations of blood into the cysts. The tongue should be kept in the mouth if possible, e.g. by applying a chin-bandage, or, if it is prolapsed, guarded from being chapped with cold and dry air by the use of a respirator, provided that these methods do not impair respiration. If the child cannot suck, it must be spoon-fed. Recurrence of inflammation and of enlargement of the stump must be ascribed to insufficient removal (Vernon), and as this complication may be dangerous in preventing recovery, it should be avoided. The line of the incision should, if possible, run through healthy muscular substance. The galvano-ocraseur should not be employed, as it will prevent union by suture ; moreover, the limits of the disease cannot be so well defined. If the disease is extensive, in- volving a large portion of the tongue, the lingual arteries may be first of all ligatured. This must, of course, imme- diately precede the excision, otherwise a free anastomosis would soon be set up. Ligature of the lingual arteries alone may possibly be sufficient in simple muscular macroglossia, as in Fehleisen's case, but would be useless in the lym- phangiomatous form.* 2. Muscular Macroglossia ; Simple Macroglossia. Galen describes a case as follows : " We saw a marked * Although I have never had to operate in a case of general macroglossia, I have many times removed local macroglossia, and have been struck with the severe haemorrhage which has more than once occurred. I would strongly urge, even in cases in which the disease appears quite superficial, that the incisions should extend well into the substance of the tongue, and that the edges should be speedily brouprht together with silk sutures. Most of the bleeding is capillary and venous, and is readily arrested by the pressure together of the surfaces of the wound. In the case of infants and children, the stitches may be passed before the incisions are made, and the hiemorrhage may be arrested by the fingers of an assistant or by flat forceps until the sutures have been tightened. H. T. B. 276 DISEASES OF THE TONGUE. enlargement of the tongue in a patient who had no pain, nor was there oedema, nor cancer, nor inflammation ; it did not pit on pressure, nor was it sensitive nor painful; it simply consisted in a great enlargement without the sub- stance of the tongue being at all altered." A case of simple muscular hypertrophy may be seen in an otherwise healthy child and go on to considerable enlargement without those recurring attacks of inflammation which characterise the lymphangiomatous form, or of an alteration of the surface of the tongue (unless this be artificially produced), or of any alteration in shape ; simply an increase in size " lingua vituli." But it is notorious that even when the tongue is merely too large for the mouth, yet not prolapsed, the intellect is generally defective, and the more marked cases usually occur in idiots. Parrot noted this, but there is no special connection with inherited syphilis, as he thought. Bruck rioted an extreme case of general muscular hypertrophy with macroglossia in an idiot. The patients may be cretins ; at birth there may be macroglossia with congenital cretinism, called also congenital or intra-uterine rickets. Another group show partial, or unilateral, muscular and osseous hypertrophy, conditions also presumably due to some congenital defect of the nervous system. The muscular hypertrophy may be partial, with symmetrical macroglossia or unilateral, with enlargement of one-half of the tongue. In case v., described by Maas, there was congenital left- sided hypertrophy of the tongue, with, at the same time, hypertrophy of the left half of the body. The skeleton as well as the muscles may be enlarged (Kopal); or the osseous and muscular hypertrophy may be limited to the face and tongue, in the area of distribution of the fifth nerve. Acquired facial hypertrophy from injury, trigeminal neuralgia, or abscess, etc., is not accompanied by any change in the tongue (Sabrazes and Cabannes). Zeisler saw a combination of the lymphan- giomatous and muscular hypertrophy in a girl, aged eight, who had muscular hypertrophy on the right side, with dilated lymphatic vesicles on the inner surface of the cheek and tongue, varying from a pin's head to a pea, also on the right side ; and a crested formation on the dorsurn of the MUSCULAR MACROGLOSSIA. 277 tongue. With respect to the microscopic examination of the portions of hypertrophied tongue removed, in some r.ises it has simply been remarked that all the structures were similar to those existing in a normal tongue ; in others, two changes have been seen an increase in the number of muscular fibres and an increase in the size of the fibres. In a case of muscular hypertrophy described by Helbing the hypertrophy was due to an increase, both hi number and size, of the fibres ; the diameter of the fibres showed remarkable variations viz. between 10 and 48 //, the largest being nearly five times that of the smallest. Eickenbusch found the muscular fibres not only increased in number, but one-third larger than the normal in a child of eight, whilst the connective tissue between the muscular fibres had disappeared. In Brack's case of idiocy and extreme general muscular hypertrophy the tongue was composed of normal, undegenerated, muscular fibres, whilst the connective tissue between was not increased. The muscular macroglossia tends to remain stationary unless influenced by secondary inflammation, caused by the teeth or by attempts at treatment. Treatment. This is not generally of an active kind, seeing that these patients are short-lived and weakly, and do not bear operations well. They can usually live by the food being put into the mouth beside the tongue. The dis- figurement caused by the tongue hanging out of the mouth is not of serious consequence, and dyspnoea is not generally set up, as inflammation is absent. It will be necessary therefore to have decided indications before operation is undertaken. An operation may be required because the patient cannot take food well, because the size of the tongue hinders breathing and prevents sleep, because the patient's intellect shows a tendency to develop but the large tongue hinders him from learning to speak. In such cases a suffi- cient portion of the tongue should be removed by a wedge- shaped incision so as to allow of the tongue being retained in the mouth. If this has to be done it should take place before the teeth and lower jaw have become much deformed. For this simple or muscular hypertrophy Fehleisen 278 DISEASES OF THE TONfiUE. ligatured both lingual arteries. A child, aged thirteen months, had the tongue projecting a good centimetre beyond the lips. After the ligatures had been applied the tongue became of normal size, whilst the next day it was swollen as much as before, and cyanotic. It then gradually decreased, and a year afterwards the tip, when at rest, lay between the teeth. During talking it could be withdrawn between the teeth and some words could be spoken. It seems hardly likely that this operation can replace the wedge-shaped excision. There must be some risk of sloughing owing to the cutting off of the blood supply on both sides, although in Fehleisen's case only the stage of cyanosis was reached. Moreover, the case was not a very advanced one; the tongue protruded only a good centimetre from the lips, and the reduction was only partial, as afterwards the tongue lay between the teeth. 3. Inflammatory Hypertrophy. Under this heading may be mentioned those enlargements of the whole or a part of the tongue which are the result of an attack of acute inflammation, or which are produced by continual or repeated attacks of chronic superficial inflam- mation. They are essentially different from macroglossia, inasmuch as the enlargement is not dependent on dilatation of the lymphatic system of the organ. They have no ten- dency to increase continuously. As a general rule, after an attack of acute glossitis, whether of the whole or only of one-half of the tongue, the swelling rapidly subsides, but the subsidence is not in all cases complete. One-half of the tongue may remain permanently larger than the other, or an indurated lump may be left in the middle of one side of the tongue. These enlargements may never disappear, but they are not suffi- ciently great to cause the patient any annoyance or even to affect his speech. Nor are we aware of any instance in which one of these enlarged and slightly indurated parts of the tongue has become the seat of carcinoma at a later date. Syphilitic Hypertrophy. We have no intention of describing here those local hypertrophies which are due to the presence of one or several gummata. These are merely passing conditions, which may rapidly give way to treatment, INFLAMMATORY HYPERTROPHY. 279 or which may be succeeded by atrophy or deep scarring of the affected portion of the tongue. But a large portion or the whole of the organ may be enlarged as the result of syphilis. The enlargement may be due to the presence of a vast number of gummata in the muscular substance, and may cause the tongue to protrude from the mouth. The nature of the hypertrophy is recog- nised by the tuberous condition of the tongue. It readily improves under treatment. Again, those conditions which produce deep and long furrows in the dorsum of the tongue are especially prone to produce hypertrophy of the parts of the tongue between the furrows. When the furrows are extensive and deep, the hypertrophy of the intervening parts may be very considerable and permanent. During the for- mation of the furrows, the return of lymph and blood from the intervening parts is probably interfered Avith ; swelling and oedema naturally result, and the parts, like some feet and legs whose circulation has been similarly interfered with, remain permanently swollen. The mischief is further in- creased by the occasional attacks of renewed inflammation to w T hich such tongues are liable. There is no difficulty in recognising the hypertrophies which are due to this cause; they bear the marks of syphilis deeply graven on them. Unfortunately, the treatment which tends to cure the ulcers does not always tend to lessen the hypertrophy ; on the contrary, it may increase it, for the constriction on which the hypertrophy depends increases with the tightening of the fibrous tissue. Even the iodide of potassium which is administered for the cure of the syphilis may aggravate the swelling of the tongue. Mercurial Hypertrophy. The excessive use of mercury for syphilis and other affections tends to exaggerate enlarge- ments from other causes. 280 CHAPTER XVI. INNOCENT TUMOURS. Congenital Tumours Lipouia, or Fatty Tumour Fibroma, or Fibrous or Fibro- cellular Tumour Fibromyoma Rhabdomyoma Cartilaginous and Osseous Tumours Amyloid Tumours Angioma, or Vascular Tumours Pajiillonia, or Warty Tumours Adenoma, or Glandular Tumour Keloid. MANY of the affections which may be classified under the term innocent or benign tumours, have been described in former chapters : ranula, dermoicl cyst, thyreoglossal tumours, lymphangioma. The tongue is, unfortunately, much more often the seat of malignant than of innocent tumours. 1. Congenital Tumours. Now that the structure of the tumours which are present at birth is for the most part known, the name has become too general a one. It would be difficult, however, to place under any other heading the exceptional case which Studenski described so well and illustrated so fully in 1834 It would now be called an included parasite, or embryonic mixed tumour, and was clearly most like sacrococcygeal and other similar tumours. The mother, between the second and third month of pregnancy, was frightened by seeing a dead horse with its tongue out. Whether this had anything to do with the disease or not, the child was born with its tongue pushed out of its mouth by a tumour situated in the middle line between the geniohyoglossi. The length of the tongue, including the tumour, was 6 inches 2 lines, its breadth 4 inches, its thickness 2 inches 2 lines. The child could not suck, and died m thirty- six hours. It had no other abnormality ; the embryonic nature of the tumour is clear. An account of the compara- tive anatomy and development of the septum of the tongue LIPOMA. 281 has been given in the first chapter (p. 10), as suggesting an origin for such tumours in embryonic rests. Other cases of mixed tumour may at rirst sight appear fatty, but on examina- tion fibrous tissue, cartilage and bone have been discovered ( riil,- i nj'i-n ). 2. Lipoma, or Fatty Tumour. Excluding the congenital lipouia, which, as just men- tioned, is often a mixed tumour, lipoma of the tongue chiefly appears in late adult life, even in men over sixty, seventy, or eighty. It appears under different clinical forms : (a) single and superficial, tending to become pedunculated ; (6) single and deep-seated, in or beneath the tongue ; (c) multiple ; (d) diffuse. (a) The most frequent form is single, situated on the border of the tongue near the tip, or on the dorsal aspect. The mucous membrane which covers it is almost invariably smooth, stretched, and devoid of papilhe when the disease attrcts the dorsum. It can be pinched up in folds over the tumour. The growth may be quite uniform, or lobed ; it is generally so soft as to fluctuate, and, through the smooth, rosy membrane covering it, may be discerned a yellowish or golden hue, highly suggestive of the character of the tissue beneath. The rate of increase is so slow that ten, fifteen, or even more years may elapse before the tumour has attained the size of a walnut or pigeon's egg a strange contrast to the rapid progress of a carcinoma of the tongue. The tumour, if left to itself, produces little inconvenience, and is not dangerous; even the surface seldom ulcerates. But when it has reached the size of a large nut, more especially when it projects in the form of a polypus from the dorsal border, it becomes inconvenient, is apt to be caught between the teeth, and is unsightly if the mouth is opened widely. (6) A tumour grows in the depth of the substance of the tongue. But it grows so slowly that it cannot be mistaken for a gunima or sarcoma. If may protrude beneath the tongue, giving the appearance formerly called a double tongue. Here it will feel so soft as to resemble a ranula to the touch, but the golden yellow colour shining through the mucous membrane, which can be pinched up over it, clearly distinguishes the two without the need of a puncture. This form of lipoma seems to grow from the middle line, although 282 DISEASES OF THE TONGUE. it may throw out lobules penetrating the muscles and appearing even beneath the skin below the chin. The fatty tumour which most strongly suggests an origin from the structures described in the first chapter as con- nected with the development of the middle line of the tongue, is that recorded by Monod. A woman, aged twenty-six, had a tumour beneath the freenum of the tongue, which had been growing for six years. It projected about one cm., had a bluish and not a yellow tinge, and apparently fluctuated. The mucous membrane was incised and the tumour shelled out. It formed a cylinder, rounded at the two ends, about the thickness of the thumb, and five to six cm. in length, situated between the muscles. On section, it appeared grey and tough. The operation was done from the mouth, but pus collected, and a counter opening below the jaw had to be made. (c) Multiple lipomata have been seen in old men by Barling and Chavasse. Barling's patient was aged seventy- five. The tumours had been noted by the patient, biit he did not complain of them when admitted to hospital as a medical patient. They were discovered by chance. They were four in number, two on each side of the edge of the front of the tongue, varying in size from five inches to one inch in diameter. Chavasse found a number of lipomata in a man aged eighty-six. They had been noted by the patient for twenty years, and the largest had reached the size of a tangerine orange, without causing important trouble. The patient declined to have the large one removed. Cauchois saw multiple lipomata in a man aged fifty-three, affected with pulmonary, glandular, and cutaneous tuberculosis. There were fatty lobules on each margin and under the tip of the tongue, symmetrically placed, and extending deeply between the muscular fibres. There was also a lipoma in the neck. The patient was very anxious to have the tumours removed. This was partly done, but suppuration followed, and abscesses burst below the jaw, which continued to discharge until his death, three months after the operation. (d) Diffuse Lipoma. Perhaps the case just mentioned might be placed in this category rather than under multiple lipoma. A remarkable case of diffuse lipoma was shown at FIBROMA. 283 the Laryngological Society of London. A diffuse lipoma of the parotid region had extended inwards behind the jaw, and spread along the side of the tongue beneath the mucous membrane. The diagnosis of fatty tumour is made by noting its duration, its lobulation, its elasticity, pseudo-fluctuation or extreme softness, the displacement of its margin by pressure of the finger, the mobility and looseness of the mucous membrane over it, its particular hue. When deep-seated beneath the tongue the diagnosis can hardly be reached with certainty until an incision is made. Treatment. A fatty tumour need not be removed unless it gives trouble. A pedimculated tumour is removed by cutting through the pedicle and tying the vessel; the wound can then be closed by a suture. A deep-seated tumour is shelled out. Multiple and diffuse lipomata, especially in old people, seldom require active treatment. 3. Fibroma (fibrous or fibre-cellular tumour). Perhaps a little more common than the fatty tumours of the tongue, to which they present many points of resemblance besides their rarity. They occur for the most part in adults, but may be noticed first in childhood, or may be congenital. They are situated on the dorsum much more frequently than elsewhere, and may occur on any part of the dorsum, even towards the root of the tongue, but, unlike the fatty tumours, they scarcely ever affect the under aspect. There may be one or several tumours : indeed, it is not unusual to see two or three, either separated by a tolerably wide interval, or lying side by side. It is probable that the fibromas, like the lipomas, commence in the substance of the organ, but as they increase in size, they project and often assume a distinctly polypoid form, on which account they have been not in- frequently described as fibrous polypi of the tongue. They probably grow rather more quickly than the fatty tumours, but the rate of increase is very slow, and after many years a fibrous tumour may be no larger than a walnut. The fibrous polypi resemble, in every respect save one, the fatty polypi ; they are composed of the softest varieties of fibrous tissue, and are rather tibro-cellular than fibrous. The mucous membrane covering them is smooth and stretched, and they 284 DISEASES OF THE TONGUE. are so soft as to appear to fluctuate. The important excep- tion is that they do not present the yellowish hue peculiar to the fatty tumours, and thus the diagnosis of one of these diseases from the other is made. But the deeper-seated fibrous tumours are much more difficult to distinguish. The mucous membrane over them may be tense and thin, but it is not adherent ; the tumour is generally rounded, but may be lobed ; it is rirm, tense, elastic, so that it may be taken for a sac filled very full of fluid. Fibromas are very seldom either painful or tender ; they are quite innocent, and give rise to very little inconvenience. But after a time they are irksome in speaking or in eating, and hence there comes a desire to be rid of them. The diagnosis, as has been hinted, is not in every instance free from difficulty. The tumour may be taken for a cyst, and the error is only rectified by an incision. Even then some doubt may still remain. Sir James Paget kindly gave us the notes of a case in which, to make the diagnosis, he punctured such a tumour ; some synovia-like fluid escaped, but finding that a solid mass remained behind, he cut it out and found it was a fibrous growth. No serious consequences are likely to ensue from an error in the diagnosis of a fibrous tumour. The treatment is precisely similar to that recommended for fatty tumours, to cut off the polypoid growths, and to enucleate those which are more deeply placed through a single incision. The appearance after removal varies ; it may be that of a dense mass of fibrous tissue ; or of bands of firm fibres intersecting a softer, yellower, and more succulent material; or of such loose and oedematous tissue as nasal polypi are made of. 4. Fibromyoma. Blanc described a pedunculated, pear-shaped tumour, the size of a large egg, which was attached to the base of the tongue and filled the pharynx. The finger was passed between the tumour and the epiglottis. The tumour was cut away with scissors. No important haemorrhage took place, and the patient was quite well five months later. The structure of the tumour was that of a fibro- myorna. He also mentions another case. CARTILAGINOUS AND OSSEOUS TUMOURS. 285 5. Rhabdomyoma. Pencil saw a boy, aged eight weeks, otherwise sound, in whom a tumour of the left half of the tongue had been noted at birth which prevented him from sticking and he had to be spoon-fed. The tumour slightly increased and commenced to ulcerate. It was, when removed, the size of a pigeon's egg, situated in the substance of the tongue, near but not quite reaching the left margin. Its surface was nodular ; its consistence elastic, but not compressible ; its colour pale red, except when the child cried, when it became bluish red. The tumour was circumscribed ; the rest of the tongue was normal, and there was no sign of muscular macroglossia or general hypertrophy. At the operation the tumour was found to be circumscribed, but not encapsuled. The main part of it was composed of young, striped, muscular fibres, with normal connective tissue and blood vessels. There were no dilated lymphatics nor sarcomatous elements. 6. Cartilaginous and Osseous Tumours. If one considers the cases of tumours in which cartila- ginous substance has been noted, it is difficult at first sight to group them together. But if one assumes that what has been described as cartilage may not have been identical in all the cases, an explanation of the differences in the cases suggests itself. Perhaps in future cases more exact histological observations will be made with regard to the cartilaginous substances. The explanation suggested is that there may be different conditions under which a cartilage- like substance may occur : (a) Congenital tumours, con- taining true cartilage ; (6) Tumours arising in scattered mucous glands, really endotheliomata, in which a cartilage- like substance forms e.g. tumours identical with those arising in the submaxillary and parotid glands ; (c) Amyloid tumours, containing cartilage and bone. () Congenital Chondroma and Osteoma. These are found in connection with the middle line of the tongue in connection, doubtless, with the foetal structures which give rise to the septum (p. 10). Weber describes a case which he had seen of a girl, fifteen years old, who had a rounded, slightly nodular mass, about the size of a walnut, growing 286 DISEASES OF THE TONGUE. in her tongue for eight or more years. It was composed largely of cartilage, but contained also a goodly quantity of fat and fibrous tissue. One cannot but suspect that the tumour in this case was of congenital origin ; first, on account of the extreme rarity of lingual chondroma in adult or almost adult age ; second, because two cases at least are described (Arnold and Bastien) of congenital tumours of the tongue which contained large quantities of fat mixed with cartilage and other connective tissues. Mikulicz and Kiimmel mention two other cases. (6) Cartilage-like tumours, mixed with fat, have been seen on the dorsum of the tongue near che root. They are not congenital, neither are there any foetal remnants in this situation ; but there are mucous glands scattered about, especially in front of the pillars of the fauces. The clinical and microscopical observations would accord with the supposition that they are similar to parotid and sub- maxillary tumours (p. 226). Berry described a tumour, the size of a hazel nut, taken from a man aged forty-nine. It had been growing on the right border of the tongue, midway between the base and tip, for five years, and was certainly not congenitil. It was composed of firm, fibrous tissue with a nodule of cartilage in the centre. Lang saw an indolent, very hard tumour, the size of a hazel nut, on the dorsal aspect of the tongue, just to the left of the middle line, and nearer to the base than to the tip. It had been growing steadily for twelve years in a woman aged twenty- two. It had a broad base, was slightly elevated, with the mucous membrane intact. It was removed, under cocaine, with trifiing haemorrhage. The wound was sutured and healed by first intention. The tumour contained cartilage, bone, fibrous tissue, and fat. 7. Amyloid Tumours. They were first described by Ziegler in 1875 in a patient who had died of chronic bronchitis and emphysema with a syphilitic liver. There were three large nodules and other smaller ones at the base of the tongue behind the circumvallate papillae, partly pressing on the epiglottis. Schmidt has described two more cases; he identified the amyloid substance both by the iodine and by the gentian A. \GIOM A. 287 violet reaction. One patient had died of bronchitis and emphysema. Between the circumvallate papilla? and the junction of the palatoglossal fold with the tongue was a hard, slightly prominent tumour, circular in outline, 15 mm. in diameter, covered by intact mucous membrane ; another 9 mm. long by 5 broad, both 8-10 mm. from the epiglottis. The yellowish waxy amyloid substance was not sharply defined, but extended into the muscle tibres around ; the hard part was composed of cartilaginous material, some of which was calcareous; other nodules were bony without showing marrow spaces. The second patient had died of emphysema, signs ot old pleurisy, ulceration of the stomach, and heart disease. In the right half of the base of the tongue was a hard nodule about 9 mm. in diameter, situated about 2 mm. from the middle line, having the same yellowish waxy character, with small islands of bony substance containing bone corpuscles and canaliculi. These amyloid masses have always been met with at the base of the tongue, just in front of the epiglottis, in patients dying of diseases in which amyloid degeneration occurs; and the cartilaginous and bony nodules in the waxy substance are similar to those met with in the trachea and bronchi, etc. As distinct from an enchondroma, these amyloid masses are not encapsuled. 8. Angioma, or Hsemangioma ; Vascular Tumours. These are benign tumours composed of blood vessels, more or less dilated arteries, capillaries, or veins, without any new growth between the blood vessels and without any dilatation of lymphatics. The blood tumours may remain stationary, or enlarge only from the pressure of the blood within, but do not show that tendency to continual extension and enlargement of the tongue characteristic of lymphangiomata. The tumour may at first appear to be only a naevus, but later show lymph vesicles. Under these circumstances, the lymphangiectasis should be considered as the essential feature, and the tumour should be classed as a lymphangioma. Vascular tumours only cause trouble by their size, and by bleeding, when the surface has been injured. The angioinata may be divided into : (a) arteriovenous, pulsating aneurysms ; Js* DISEASES OF THE TONGUE. (6) cirsoid aneurysms, or aneurysms by anastomosis; (c) capillary nsevi ; (d) venous mevi, or cavernous tumours, which are the most frequent. (a) An arteriovenous aneurysm may form after an injury, such as a punctured wound under the chin. Despres saw an arteriovenous aneurysm of the tloor of the mouth of a girl, aged sixteen ; it had commenced when she was twelve, and showed itself by its pulsation and thrill. Both lingual arteries were ligatured, and this led to some improvement, but a thrill remained, for which pressure on the carotids was tried at intervals. A pulsating tumour may be quite small, as in Gay's case, where the tumour was the size of a pea, situated near the tip. It had existed six months, when it began to bleed spontaneously. (6) Cirsoid Aneurysm, Aneurysm by Anastomosis; also Teleangiectasis, or Plexiform Angioma. A few instances have been recorded in the tongue. The tumours are more detinitely circumscribed than venous nsevi, and the vessels possess a distinct wall. In a case related by Bryant the tumour occupied the tip and right side of the anterior half of the tongue. These parts were congested, swollen, and covered with large full veins, while great tortuous arteries could be felt run- ning up from the base of the tongue to supply the tumour. It could readily be emptied by pressure, but filled again the instant the pressure was removed. It was not treated. In a case related by Fayrer, the tumour occupied the situation of a ranula, and at first looked not unlike a ranula ; but, when closely examined, it was found to have a tortuous, lobulated configuration, and it pulsated strongly. It was as large as a small orange, had existed eight years, during which time it had on several occasions bled violently, and it was said to be steadily increasing. Fayrer punctured it, and a jet of arterial blood spouted up through the opening. He then injected it with a strong solution of tannic acid; the haemorrhage and pulsation were imme- diately arrested. The tumour continued to consolidate during several days, when the man, a native Indian, dis- charged himself from the hospital, and was not seen again N&VI. 289 by the surgeon. Both these patients were males, one of them thirty, the other forty, years of age. Mott also described an aneurysm by anastomosis on the left side of the tongue. (c) Capillary Ncevi. Small congenital na?vi, similar to those seen on the skin, also occur on the tongue. They are often multiple, occurring on different parts of the body as well as on the mouth and tongue. In Mendel's case there were numerous naevi on the lips and cheek, and also on the tongue in front of the V. Reinbach saw a pair of congenital naevi, one on either side of the fraenum. These naevi are said to arise in the line of the fissures of the embryo. As often as not, they are seen at a distance from any fissure. To accord with the fissure theory, the capillary naevi should be seen in the middle line or else along the line of the V, which is by no means the case, unless some secondary displacement is assumed. A port-wine stain on the face, naevus vasculosus, may be continued into the mouth. Acquired Capillary Ncevi. Treves has described three cases, all in adults (two appeared in women during preg- nancy), in which capillary nsevi first appeared long after puberty and caused haemorrhages. His first case was that of a healthy, rather plethoric, man, aged fifty - seven, who had suffered from epistaxis since childhood. Several members of his family, his grandfather (died aged eighty- one), his father, two uncles, and t\vo brothers, his son, and two daughters, all had suffered from recurrent attacks of haemoptysis, but there was no distinct history of haemo- philia. The man's epistaxis recurred every two to six weeks, preceded by headache. Four years before Treves saw him he began to bleed from the tongue, and had not since then suffered from epistaxis. The bleeding had increased of late, so as to render him anaemic. The tongue, otherwise normal, had nine bright red tumours dotted about, the largest the size of a split pea, the smallest that of a pin's head, the colour of which disappeared on pressure. The haemorrhage was arterial and spontaneous, on or after eating. The tongue was painted with chromic acid 10 per cent., which stopped the bleeding from the tongue, 290 DISEASES OF THE TONGUE. but the epistaxis returned. The second patient, a woman, aged thirty-one, had suffered from occasional attacks of headache which quite prostrated her. She had always lost much at each menstrual period, but had no piles or vari- cose veins, and had never bled from the nose. The bleeding, which was often severe, came from a tumour, not unlike a raspberry. It had no visible pulsation, and could be easily reduced to a mere tag by pressure. It had grown without pain during her last pregnancy. The hemorrhage was always spontaneous, and sometimes alarming in amount. Since the bleeding she had had no more headaches. The tumour was snipped oil and the base cauterised. Under the microscope the tumour appeared a pure arterial angioma. Butlin had a similar case under his care in St. Bartho- lomew's Hospital. There were several tiny, bright-red spots on the dorsurn of the tongue of a married woman, and one larger place about the middle of the fore-part of the tongue, which formed rather a depression or small cavity than a tumour. Profuse bleeding occurred from these bright spots, especially from the largest place. The tiny spots precisely resembled the tiny naevi which are seen on the septum nasi in certain persons who are liable to frequent attacks of epistaxis. The galvano - cautery sufficed for the cure of the little nsevi, as it does for those in the nose. (d) Venous Naivi or Cavernous Tumours. Venous angi- omas are generally congenital, but this is not invariable, for, if their history is to be credited, they originate occa- sionally in the tongues of adults. They may occur singly, or to the number of three or four or more ; and, in either case, are situated generally on the dorsum, more often in the anterior than the posterior half. There they project slightly above the surface, lifting up and thinning the mucous membrane over them, and generally showing a dull blue or livid colour through the thinned membrane. As in the integument covering many of the external nrcvi, so in the mucous membrane covering the lingual njevi, small varicose vessels and vascular spots may be observed. In some instances the contents can be slowly pressed out of the CAVERNOUS NsKVI. 291 tumour, but in other instances the mass feels tense and elastic, like a thin cyst tightly filled with fluid, and cannot be reduced even by firm and long-continued pressure. Nsevi of the tongue are seldom very large, not reaching usually to the size of a large nut. They are usually quite painless, and give rise to no inconvenience save by their bulk; yet they may bleed, and if by misadventure they have been pricked, may bleed profusely and repeatedly. Venous nsevi are generally circumscribed, and are supplied by an afferent artery and efferent veins. The vessels and the blood spaces have developed a distinct tumour, so that if injected through the artery, the injection fills the spaces and escapes by the veins, but does not spread to the capillaries of the surrounding tissue. A nsevus, though congenital, may give rise to no trouble during the life of the patient. Or, it may begin to grow larger during adult age, and may on that account need treat- ment. The most formidable case occurred in a man, forty-six years old, who came to Butlin from the hot regions of Australia, where he had lived for many years, and had been accustomed to drink freely. All the anterior two-thirds of the tongue was transformed into a huge cavernous nsevus. He said the condition was congenital, and a similar nievoid condition of the lower lip made this very probable. During the last few years the tongue had slowly grown larger, and nine weeks ago it had become painful and ulcerated. The pain and the fear ot fatal haemorrhage had forced him to seek for relief by operation. The whole of the anterior two- thirds of the tongue was removed, after a ligature had been tied round it behind the line of incision. The patient made a good recovery, and was quite well when seen some years later. The specimen is preserved in the museum of the Royal College of Surgeons (No. 2267). In Hulen's case the tumour had existed for twenty years in a woman aged forty-three, and had not varied at all during that time. It could be emptied by pressure, and refilled without thrill or pulsation. Carter described a well-marked instance of the late development of a cavernous naevus. A man, aged fifty, had a tumour occupying the right half and the tip of the tongue. 292 DISEASES OF THE TONGUE. It had commenced spontaneously ten years before, about the middle of the right border, and had grown rapidly during the last six months, unaccompanied by symptoms. It could be emptied by pressure and refilled without pulsation. After removal the tumour, preserved in spirit, measured 3i inches by an inch. It was covered with enlarged filiform and fungiforui papillae, below which was cavernous tissue with a few muscular fibres. What at first seems to be only a ntevus may after- wards prove to be essentially a lyrnphangioma. Bryant has described this change in a case he had unusual opportunities of watching. The diseased portion of the tongue became tolerably firm and harder in some places than others ; the surface changed and looked like being made up of vesicular warts, the vesicles being filled with clear or bloodstained serum (Pl^VIL, Fig. 2). The growth continued in the deeper parts, while fresh tumours continued to form in the vicinity. A painless, ill-defined swelling appeared below the jaw, which, when punctured, yielded a thin, watery, highly albu- minous fluid. This case clearly shows the steady advance of lympliangiouja to produce marked macroglossia. A nsevus may become partly obliterated by fatty de- generation. A nsevus is usually very easily recognised. Its situation on the dorsal aspect of the tongue, its bluish colour, its solt consistence, the ease with which it can usually be diminished in size 1by pressure, the rapidity with which it refills, and the appearance of vessels and vascular points upon its surface, permit no doubt" to exist regarding it. Unless a lingual naevus is obviously diminishing in size, and there is thus a reasonable prospect that it will undergo spontaneous cure, it should be treated, and the earlier the treatment is undertaken the better, Small superficial nsevi may be cured by destroying them with the actual or, far better, the galvano-cautery. Even nrevi as large as a small nut may be easily destroyed by two or three applications of the galvano-cautery ; the point of one of the platinum instru- ments should be made to penetrate deeply into the substance of the growth and "moved in all directions through it until it has been completely broken up. The swelling and inflam- PAPILLOMA. 293 ination which follow this operation are comparatively trivial, and the nievus is sometimes cured by a single application. If it shows signs of returning vitality the operation must be repeated. If a dull red heat is employed there is no hemorrhage. The application of ligatures en masse was formerly employed, and was exceedingly painful ; it was followed by sloughing of the tumour beyond the ligatures, which set up, in many cases, fatal septic pneumonia. This plan has been, or should be, entirely discarded. In an infant, aged four months, Heaton found the tongue swollen and protruded from the mouth, causing dyspnoea, owing to a venous nsevus. Electrolysis led to no improvement ; ligature of both lingual arteries caused a temporary reduction, but swelling recommenced and death followed from asphyxia six months afterwards. The most satisfactory operation is excision, keeping out- side the margin of the vascular tissue, where the vessels can be usually caught and tied. If a wedge-shaped incision can be made, the wound may be drawn together and the owing checked by pressure. In some cases where there is much oozing excision may be done with the cautery knife at red heat, or this may be used to sear the cut surface. Excision is always necessary where there is any sign of lymphangioma. For very diffuse venous naevi, arteriovenous aneurysms and cirsoid aneurysm, a preliminary ligature of the linguals may need to be adopted ; then the angioma may be excised, or treated by electrolysis at several sittings, the ligature of the arteries alone being insufficient to arrest its development. 9. Papilloma (warty tumour). Warts and warty growths are among the more common of the innocent tumours which aftect the tongue. They occur most frequently upon the dorsum within the papillary area, and are then doubtless due to hypertrophy of the natural papilla 1 : but they are not limited to the papillary area, and may even grow on the under aspect where the mucous membrane is quite smooth. They may occur at any age, and are not uncommonly congenital. A remarkable case occurred in a little boy who was a patient in St. Bartholomew's Hospital some years ago. He had a warty enlargement of all 294 DLSEASES OF THE TONGUE. the fungiform papillae of his tongue ; there was not one of them, so far as we could judge, which was not hypertrophied and warty. Each fungiform papilla stood up on the surface of the mucous membrane as a small white papillary tuft. So, at the Hospital for Sick Children, a little warty tumour was seated sessile on the under aspect of the tongue of an infant ten months old. It projected to the left of the freenum in the groove between the tongue and the floor of the mouth. Papillary growths are almost always compound (Fig. 24) ; they may be either single or multiple. Under the name of papilloma, cases are also recorded which come under the heading of glossodynia or neuralgia of the tongue. Papillae, sometimes fungiform, sometimes in the region of the foliate papilla, become swollen and are extremely painful. Other papillornata are due to irritation, and occur on each side of the framum in children, owing to the contact of the under-surface of the tongue with the sharp incisor teeth during whooping-cough, etc. They have been called on the Continent Riga's disease. A remarkable tumour was seen by Vincent in a child two months old. It formed a large mass, thicker than the tongue on which it grew, and consisted of exaggerated papillae on the surface and of fibrous tissue beneath, giving a sensation of wooden hardness. But the chief interest in connection with papillomata is to be found in those sessile warty growths which form on tongues which are leucomatous or the seat of chronic superficial glossitis. Several of them are figured in the plates (V., VII., VIII). They look, at first, much like an extra thick patch of leucoma, but as they grow larger and more prominent, the warty character is more pronounced. They will be again referred to in the chapters on carcinoma of the tongue, for they are so invariably the actual pre- cursors of cancer in such tongues, that we believe every such warty growth becomes cancerous if it is left untreated. As they grow larger, they also become more fixed, and induration gathers about the base. This is the earliest indication of the change to cancer; but it is impossible DIAGNOSIS OF PAPILLOMA. 295 to tell the precise moment at which the innocent growth becomes malignant. The diagnosis of a papilloma, in most instances, presents no difficulty. In children and young persons it can only be mistaken for a condyloma. We have more than once Fig. 24. PAPILLOMA. Photographed from a vertical section through a papilloma removed from the tongue by Spencer. It is composed of elongated papillse with thickened epithelium, which is also thickened on the pedicle and on the surface of the tongue beyond. The centre of the pedicle is composed of fibrous tissue. This case would probably have soon become epitheliomatous so as to resemble Fig. 25, p. 319. seen a warty syphilitic growth on the under aspect of the tongue, where it was out of reach of injury or irritation, so like a papilloma, that we doubt whether the diagnosis could have been made unless a clear history or some other signs of syphilis had been present. On this account it is always well to examine the patient closely for syphilitic symptoms, especially if he is a young adult and the tumour has not existed very long. The syphilitic growth rapidly disappears under the local application of a ten-grain solu- tion of chromic acid ; but we are not aware that the acid produces any effect on a true papillary growth. 296 DISEASES OF THE TONGUE. In persons more advanced in life, especially in men, and more especially in those who suffer from chronic super- ficial glossitis in any of its forms, it is exceedingly difficult to make the diagnosis between a simple warty growth and an epithelioma. The absence of ulceration, of fixity of the tumour, and of induration about its base, indicate an inno- cent growth. The presence of these signs make it almost certain that the disease is already malignant. Even a microscopic examination will hardly discover the difference, in the transition period from the one to the other. Yet the diagnosis is important; for, although removal without delay is the treatment for both diseases, the extent of the operation is very different in the two cases. The innocent growth may be removed with only the base on which it grows. The malignant growth calls for the removal of a wide area of the surrounding tissues. The treatment of papillomata is very simple. They should not be allowed to remain, and should not be treated with caustics, unless the caustic is applied in such a manner as to completely destroy the tumour. They can be readily destroyed with the galvano-cautery if they are of small size; or they may be removed with the galvano- cautery loop. The pain of the operation may be allayed by painting the tongue freely with a 20 per cent, solution of cocaine. The operation is not imperative in children and young persons, although it is very desirable, even in them, to get rid of a disease which tends to grow slowly larger, and which is likely, in later adult age, to form the foundation of malignant disease. In persons over thirty years of age the sooner all such growths are taken away, the better. If the tumour is very small, and of recent growth, in an otherwise healthy tongue it may be taken away with the galvano-cautery loop, Avhich should enclose the surtace on which the wart stands. There will then be no fear of recurrence. For all large growths, and for all suspicious growths, and for all papillary growths on diseased tongues, the only safe operation is the removal of the tumour with a wider base than that on which it stands And the best way to perform this is to cut out the base by two elliptical incisions which pass deeply down into KELOID. 297 the substance of the tongue, so that the edges of the wound can be brought together by sutures and healing by the first intention can be secured. 10. Adenoma, or Glandular Tumour. There are no tumours of the tongue to which the name of adenoma properly belongs, except it be to those occasional tumours which arise in the mucous glands. These are referred to in Chapter XII. Besides those which grow in the glands beneath the tongue, hypertrophy of Blandin's gland beneath the tip of the tongue has been seen, also of glands on the back part of the tongue in front of the anterior pillar of the fauces. As to those tumours which have been described as adenomata, the insufficiency of the histological description prevents one from identifying them. 11. Keloid. The only case of keloid with which we are acquainted is that related by Sedgwick in the Pathological Transac- tions for 1861. The patient was a little girl, between four and five years old, who had patches of keloid on several parts of the body. A short time before her case was brought before the Society a patch appeared on the right side of the tongue, and quickly spread along the upper margin towards the tip. It looked, when the tongue was protruded, like the contraction consequent on some surgical operation, or a severe burn, or the application of some corrosive to the part. It was very little indurated. Sedgwick regarded the disease as a good example of Addison's keloid. A case, which appeared to be somewhat similar in kind to this, was under the care of Mr. Morrant Baker, in St. Bartholo- mew's Hospital, in 1881. The patient was a healthy-looking man of twenty-three years old, who had on the left border of his tongue a perfectly smooth concave depression, sur- mounted on the dorsal aspect by a very smooth curved border raised to the extent of an eighth to a quarter of an inch, and slightly everted. The border was a little firmer than the surrounding parts, otherwise there was not any induration. The disease was said to have followed a bite of the affected portion of the tongue. Mr. Baker removed the disease, with about a quarter of an inch of the adjacent tissues, but we are not aware whether it recurred. 298 CHAPTER XVII. MALIGNANT CONNECTIVE-TISSUE TUMOURS, OR SARCOMAS. Tumours not proved to have been Sarcomas Varieties of true Sarcomas : (a) Sar- comas relatively benign without glandular enlargement ; (b~) Malignant Sar- comas involving Lymphatic Glands ; (c) Small Round-celled Sarcomas or Lymphosarcomas at the base of the Tongue ; (r/) Sarcomas following Con- genital Lymphangiectasis ; (e) Sarcomas connected with Mucous and Salivary Glands ; (f) Secondary Sarcomas Diagnosis Causes Prognosis Treatment. 1. Tumours not proved to have been Sarcomas. A CASE was reported by Professor Jacobi, of New York, in the American "Journal of Obstetrics," for 1870. The tumour was congenital, about the size of a walnut, seated in the dorsal aspect of the tongue, quickly growing. It was elastic, rounded, deeply grooved, and ulcerated. In colour it was bright red, being covered by a very large network of capillaries. It was removed successfully with the galvano-cautery, and after removal was found to con- sist partly of round, but chiefly of spindle cells. There is doubt whether this was in truth a sarcoma ; it might have been composed of embryonic tissue on account of the extreme youth and immature condition of the infant. On further consideration, Jacobi's case would appear to be one of angioma or fibrous nsevus. Another case was that of a patient under the care of Godlee, in University College Hospital. The tumour was seated on the dorsum of the tongue, was somewhat pendulous, and recurred after it had been removed. Later there appeared several growths on the skin of different parts of the body. Barker mentions the case, and suggests, what is by no means improbable, that it was really a case of multiple sarcomata. In the previous edition no attempt was made at a general description of such a rare affection as sarcoma of the tongue ; SARCOMA OF THE TONGUE. 299 but public attention having been drawn to the matter, a number of cases have been recorded under the heading " Sarcoma of the Tongue." They appear, however, to be of very different quality, and we are doubtful whether they can be properly classed under one name, unless it be that of " malignant connective-tissue tumour." Under the name of " sarcoma of the tongue " Marion has collected twenty-four cases, yet one must express astonishment at some both of his inclusions and exclusions. Of course, it is impossible to review with certainty the conclusions reached, and the names given to cases of an earlier date, in some of \vhich a first-hand account has not been available. All that one can do is to exclude from the category of sarcomas those cases in which there is no sufficient proof that the tumours were really malignant connective-tissue tumours. Marion specifically excludes the cases of small round- celled tumours, in which mention is made of a fine reticulum between the cells, saying that they grow from the lymph- adenoid structures at the base of the tongue. On the other hand, he includes such tumours in his list when no mention is made of an intercellular reticulum. But the microscopical descriptions of the tumours removed have usually been very brief, and unless the sections were carefully examined, e.g. by first getting rid of most of the small round cells, the existence of a reticulum may have been overlooked. Whilst not including Hutchinson's and Eve's cases -of lymphosarcoma, Perman's case is reckoned as one of sarcoma. Surely the account given by Perm an shows that his patient had hyper- trophy of the lingual tonsil. A woman, aged thirty, had pains in the throat and a little occasional bleeding. A swelling at the base of the tongue was seen by the laryngeal mirror. The cautery was first applied, later on portions were snared off, and pyoctanin injected, followed later by the removal of further pieces with the snare. After four months of this treatment there was still a swelling at the base of the tongue which gradually subsided. Onodi's case is also included by Marion amongst the sarcomas. A girl, aged fifteen, had a tumour at the base of the tongue the size of a small nut, which had been noted six months before. A small piece was removed, and a month 300 DISEASES OF THE TONGUE. afterwards the condition was unaltered, the hollow remaining from which the piece had been removed. It is not a character of sarcoma to remain stationary after a piece has been punched out of it, and the case accords with hyper- trophy of a lyinph follicle. Even the irritative tumours on either side of the frsenum of children (Riga's disease, page 294) have been included among the sarcomas by Marion and Targett. There are also cases named sarcoma the description of which is similar to that of others called hypertrophied papillae, or pedunculated fibromas. Mercier's case, which is called a spindle-celled sarcoma, was a mushroom-shaped tumour which had existed eight years. It formed a tumour the size of a large nut, composed of spindle cells with fatty degenera- tion in the centre. The tumour had been stationary for the four months preceding its removal. Mikulicz and Michelson in their Atlas (Taf. xxxv.) describe a small pedunculated tumour, 1*5 cm. in diameter, of three months' duration. Its pedicle, which was 5 mm. in diameter, was quite superficially attached. It was cut off and the attachment burnt with the cautery. It is impossible to say that some of the cases recorded long ago were not sarcomas, but one cannot accept the state- ment that Heath's case was a sarcoma. Marion places it at the head of his list as a round-celled sarcoma. Heath described the case -as one of medullary cancer, but we have elsewhere given reasons for believing it to have been an epithelioina. Another case included as sarcoma by Marion is one briefly mentioned by Hueter in 1869. A tumour the size of a hazel-nut had been removed from a woman in the seventh month of pregnancy, after it had been noticed two months. Nothing is mentioned about a microscopic examination, nor even that the question of its being a gumma had been con- sidered and excluded by treatment. Bleything has recorded, under the name of sarcoma, an ulcer which was probably due to chronic traumatism. A young man, aged seventeen, developed an ulcer on the tip of the tongue, which was attributed to cigarette smoking. It was cauterised with nitrate of silver, and the ulceratiori and TRUE SARCOMAS. 301 induration increased. A piece was cut out for diagnosis, and then the ulcer was excised, and was stated by Delafield to be a round-celled sarcoma. Six years later the tongue showed simply a linear scar. The so-called sarcomas of the tongue of cattle are now known to be due to actinomycosis. Having therefore shown upon what doubtful grounds many cases have been called sarcoma, one passes to those which appear to be correctly described under this name. In doing so one may observe that sarcomas of the tongue as a whole cannot be regarded as much less malignant than epithelial cancer. Some are as malignant as the most malignant cancer; others are very favourable for removal, especially when encapsuled or, at least, circumscribed. They are composed of round or spindle cells. The round cells in some are large ; in the tumours growing from the base of the tongue the cells are small, the tumours being called also lympho-sarcomas. But the small round-celled or lympho- sarcornas are not confined to the base of the tongue. The sarcomas which have been hitherto described fall into several groups. True Sarcomas. (a) Sarcomas of a relatively benign character arise in the muscular substance of the tongue, causing a smooth elevation of one or both sides, without glandular enlargement. A case of small round-celled sarcoma was seen by Butlin in a man, aged forty, who had not had syphilis. He had smoked cigars, but not a pipe. He had noted the tumour as well as a soreness for two months, and had been treated with iodide of potassium unsuccessfully. The left half of the tongue was enlarged by a tumour the size of a fives ball, without ulceration of the surface. Beneath the jaw the submaxiliary gland was enlarged and hard. The left half of the tongue, to which the tumour was entirely limited, was removed, and the tumour found to be of a soft consistence, white colour, circumscribed, but not actually encapsuled, and composed of small round cells. The enlarge- ment of the submaxiliary gland subsided when the pressure on the duct was removed. No recurrence had taken place some years later. The tumour is preserved in the museums 302 DISEASES OF THE TONGUE. of the Royal College of Surgeons and St. Bartholomew's Hospital. Dunham has described a case of large round- celled sarcoma. It occurred in a man, aged sixty-one, who was a moderate drinker, but had smoked much. A brother and sister had died of tuberculosis eight months before. The tumour grew until it reached one inch and a half in diameter, on the right margin of the tongue opposite the first bicuspid tooth. The epithelial surface was intact, although the patient said that he had bitten his tongue, and that a blister had been raised by the irritation of decayed teeth. After removal an examination confirmed the unaltered condition of the surface, and there was no down-growth of epithelium into the sub-epithelial tissues. The tumour was composed of cells of a large size lying amongst a delicate fibrous reticulum of small amount ; there were no spindle cells ; glandular enlarge- ment was absent. Abbe removed, under cocaine anaesthesia, a mass which had been growing some years buried in the dorsum of the tongue, and had reached to the size of the end of the thumb. It was found to be a vascular sarcoma. Barling in 1896 operated upon a similar case to Butlin's, and he has informed us by letter that his patient is alive and well three and a half years after the operation. A woman, aged thirty-five, had noticed a small swelling on the tongue four months before operation. It grew in spite of the administration of iodide of potassium, until an elastic, round swelling occupied the left half of the tongue, extending up to the septum, and bulging both on the upper and under surface. It was not very tender ; the surface showed no inflammation nor ulceration of the mucous membrane. The tongue was quite free, and no glands were enlarged. A piece was excised for microscopic examination, and the growth rapidly fungated through. The left half of the tongue was removed, and a tumour was found embedded in it the size of a large horse-chestnut, having a distinct capsule, and being easily enucleated. It was moderately firm, not brain-like. On microscopic examination it proved to be a round-celled sarcoma. (b) Malignant Sarcomas involving Glands. A second group have shown themselves to be malignant, recurring, and requiring more than one operation ; or recurring and SARCOMAS INVOLVING GLANDS. 303 spreading to the glands in the neck, ultimately terminating fatally. Mikulicz has illustrated in his Atlas (Tafel xxxvii.) a spindle-celled sarcoma occupying the anterior third of the tongue on both sides, which had been noticed for six months. The diseased portion was amputated, but recurrence in the glands required a second operation six months after the first one, and a third six months after the second. Two years after the third operation ulceration occurred in the scar, but following the removal of carious teeth the ulcer healed. Marion describes a similar spindle-celled sarcoma operated upon by Berger. A youth, aged seventeen, had noticed that for six months he often bit the side of his tongue, and for two months a small tumour had been growing on the edge of the tongue. The projecting portion, about the size of a nut, was somewhat pedunculated, but there was also an extension into the substance of the tongue. This was freely removed, along with a certain amount of healthy tissue around. A month afterwards there was recurrence in the scar, with enlargement of the glands below the jaw ; consequently the submaxillary glands were removed on both sides, also the submental glands, the left cheek divided, and the sarcoma very freely removed from the tongue. The recurrent tumour was of the same structure as the primary growth viz. spindle-celled sarcoma. Only an inflammatory change was perceived in the enlarged glands. A month later there was again a recurrent tumour in the scar the size of a pigeon's egg, but no fresh glandular enlargement. This tumour was again freely removed, after dividing the cheek and, this time, also the lower jaw. Two centimetres of healthy tissue around the tumour were included in the excision, which Avas done by the cautery. A month later a small tumour had formed again in the scar, and grew rapidly at first, then came to a standstill. After three months it began to get smaller, and after six months had quite disappeared, leaving an indurated scar. Healing was considered to be definite eleven months after the commencement of the primary tumour. An element of doubt is thrown upon this case by its termination. All the recurrent tumours resembled the primary one in their clinical characters, and appeared within a month of the operation. The last formation was evidently 304 DISEASES OF THE TONGUE. inflammatory ; so also were the enlarged glands removed at the second operation. Hence it may be questioned whether the primary tumour and the two first recurrent ones were really " malignant connective-tissue tumours." Targett records the case of a man, aged sixty, who, a year before, had noted a tumour the size of a horse-bean which continued slowly to increase. A globular non- fluctuating tumour was found on the left side of the frsenum, and a mass harder than the substance of the tongue extended back to the last molar tooth and caused a swelling to be felt bimanually in the submaxillary region. The surface was not ulcerated. Deglutition was not im- paired. Antisyphilitic treatment had no result. The left half of the tongue was removed. Fifteen months later there was a large recurrent mass beneath the jaws, and symptoms suggesting secondary growths in the lungs. The tumour, when examined, was found to be embedded in the muscular substance of the tongue, being well denned but without a distinct capsule. It was very soft and vascular, composed of small round cells, remarkably uniform in size. There were broad strands of muscular fibres with vessels, or degenerated fibres between portions of the new growth. A more malignant case still has been fully described by Littlewood. A patient, aged seventeen, had been quite well until March 21st, 1896, when he scalded the dorsum of his tongue whilst eating a potato pie. A "sore place" formed, which never healed up. On April 12th there was an ulcer the size of a sixpence, and growth continued in spite of treatment. On July 28th a tumour occupied the middle of the tongue, nearly filling the mouth, so as to render articulation difficult, and mastication and deglutition well-nigh impossible. There was ulceration on the surface. On August 1st the tongue was removed by Syme's opera- tion, and on August 23rd enlarged glands from both sides of the neck. The left tonsil and then the fauces became invaded, then other glands in the neck ; also a mass formed in the left temporal muscle. The patient died on December 29th, i.e. nine months after the scald. The growth was a medium-sized round-celled sarcoma, with many cells in active division, and numerous and extensive ha3morrhages. 305 (r) Si, ,'il I i-<>an i Hi/ upon Congenib'l Lymphangiec* tasis. In the two following cases there seems to be clear evidence that the sarcoma was preceded by a condition of congenital lymphangiectasis, from which a small round- celled sarcoma or lymphosarcoma started. In the College of Surgeons' Museum there is a Hunterian specimen (No. 2269) which has been described by Eve. It consists of a tongue with a round tumour on the left side of the base covered by normal mucous membrane. The SARCOMA AND LYMPHANGIECTASIS. 307 tissues around, including the glottis, are redematous. Micro- scopically the tumour consists of fibrous tissue, with masses of lyrnphoid cells between, with largely dilated lymphatic spaces. Perkins describes one which had the same origin. At four years of age a boy had a projection the size of a pin's head on the upper surface of the tongue. At twelve years the tumour had grown to the size of a walnut, pro- jecting on the upper surface and bulging underneath the tongue. It then ceased to grow until twenty-five, when it was removed locally. In a year it began to grow again, so as to fill the mouth and cause a subluxation of the jaw when the mouth opened, but the growth was still wholly within the tongue and had not yet involved the floor of the mouth or the submaxillary glands. The anterior three- fourths of the tongue were removed through the mouth, the line of division being three-quarters of an inch behind the tumour. He remained free for one year and a half, and had then recurrence in the stump and enlarged lymphatic glands in both submaxillary regions. He de- clined further operation. The tumour was a fibro-sarcoma ; fibrous bands divided it into lobes, with masses of small, rounded cells between the bands and isolated connective tissue fibres amongst the small round cells. Although no dilated lymphatic spaces are mentioned, the clinical history and a comparison with the previous specimen described by Eve suggest an identical origin. (e) Secondary Sarcoma of the Tongue. James records one secondary to sarcoma of the oasophagus. A white, soft new growth encircled four inches of the lower part of the O3sophagus : it was composed of alveoli packed with spindle- shaped cells, whilst a similar growth was found in the tongue and in the glands of the neck. The disease had been noticed three months. On the diagnosis and treatment of sarcoma of the tongue it is yet too early to speak. It will be evident to whoever studies the subject that masses which are not even new growths, tumours which have not originated in the tongue, tumours which have no real pretensions to be sarcomas, have been grouped together under the common heading of sarcoma of the tongue. We have endeavoured to 308 DISEASES OF THE TONGUE. sort out the truth from this confused mass of material, and to place it before the reader in a clearer light. But we cannot pretend to lay down any directions for the general diagnosis of a tumour disease which presents such different clinical characters and which has rarely been diagnosed correctly before removal. The question of treatment is as difficult as that of diagnosis ; for, while some sarcomas appear to be singularly malignant, there are others which are cured by a very simple operation. The sarcoma which Butlin removed is an example of the latter class : it was large and not encapsuled, although it was very well-defined. The half of the tongue in which it lay was removed, but that only included a thin layer of healthy-looking tissues on the median aspect of the tumour. It certainly appeared likely to recur, and it seemed a pity that the operation had not been larger, when we came to know the general and microscopical characters of the disease. But, several years after the operation, the man was quite well and free from any sign of recurrence. In Butlin's and also in Bloodgood's case the submaxillary gland was enlarged owing to the compression of its duct by the tumour. The swelling of the gland subsided after the removal of the tumour. Probably the wisest course in regard to treatment is to make a wide sweep in the removal of tumours which are suspected to be sarcomas ; and, if there is recurrence of a growth which has been diagnosed as a sarcoma, to remove the recurrent disease by an .operation which shall take away a considerable area of the surrounding apparently healthy tissues. 309 CHAPTER XVIII. CAKCINOMA OF THE TONGUE. Incidence of Cancer of the Tongue with regard to : (a) All Cases of Cancer ; (6) The Position of the Cancer on the Tongue ; (c) Sex ; (d) Age ; (e) Rank in Life Causation of Cancer : (a) Cause ; (b) Predisposition and its Inheritance ; (<) Exciting Causes Smoking, Syphilis, Caustics Development of Cancer Pre-cancerous or Potentially Cancerous Conditions following : (a) Leukokera- tosis or Leucoma, histological appearances ; (A) Syphilitic Ulcers and Scars Varieties of Cancer and Subjective Symptoms Pathological Histology Infection of the Lymphatic Glands The later Course and Termination of Cancer Dissemination Diagnosis. ONLY one variety of carcinoma attacks the tongue, viz. squamous - celled carcinoma or epithelioma. Glandular carcinoma has not been found, except in connection with the submaxillary salivary gland. There are great variations as to size of tumours, the extent of ulceration, the hardness or softness of the growth, the rapidity or the reverse with which the lymphatic glands are infected ; but these are only variations of the same species of cancer. 1. Incidence of Cancer of the Tongue. (a) With regard to all Gases of Cancer. Among 4,600 cases of cancer collected from various papers by Jessett, those with cancer of the tongue numbered about 400, i.e. 8 to 8 - 5 per cent. It is well known that the death-rate from cancer exhibits a tendency to increase, and this includes cancer of the tongue. Year 1897. Sixtieth Annual Report of the Registrar- Genial of Births, Marriages, and Deaths in England. London, 1899. Population of England and Wales (estimated middle of 1897), 31,055,355. Males, 15,047,580; females, 16,007,775. Total deaths from cancer, 24,443 ... Males, 9,573 ; females, 14,870 (078 p.c., 78 in 100,0(10 (39 p.c. of all (61 p.c.) of population) cancers) 310 DISEASES OF THE TONGUE. Tongue ... ... 550 ... Males, 477; females, 73 (2 p.c. of all deaths (80 p.c. of all cancers (14 p.c.) from cancer) of tongue, 5 p.c. of all male cancers) Mouth 157 ... Males, 130; females, 27 Pharynx and throat 301 ... Males, 221; females, 80 Names of Cancers of Tongue used. Cancer, Carcino- iu;i. Malignant Disease. Scirrhus. Epithelinina. San-<>iii:i. Males 267 2 207 1 Females . 49 24 316 2 231 1 (6) With regard to the position of the cancer on the tongue, no part of the tongue is exempt from carcinoma, but the posterior half is not nearly so frequently affected as the anterior half, and the edges are more subject to it than the dorsum or the under surface. There is not any difference in the liability of the two sides to the disease. Nor is there the least reason to expect there would be any difference, for the conditions which lead to the for- mation of carcinoma are such as occur with equal frequency on both sides. The following table shows the relative frequency with which the different parts of the tongue were affected in eighty cases of carcinoma which Butlin collected : Root l Anterior half and tip 3 Right border 12 Left border 17 Right side 11 Left side 16 Border... ... ... 1 Dorsum ... ... ... ... ... ... 15 Right underside ... ... ... ... ... 2 Left underside 1 Whole tongue 1 Total 80 Pre-cancerous conditions are much more common in the forepart of the tongue and at the borders than behind the circumvallate papillae. Injuries and irritation, caused by the teeth or by tobacco smoke, affect more especially the anterior part of the tongue. The back part of the tongue is very vascular and rich in lymphoid and mucous INCIDENCE OF CANCER. 311 glands, but it is not so liable to injury and irritation except during the act of swallowing. Moreover, the absence of papill.T prevents fur from collecting, whilst various kinds of organism are always clinging to the filiform and fungi- tbrm papilla 1 even in the cleanest tongue ; and, although the parasitic origin of cancer has not been demonstrated, yet it is interesting that the greatest liability of the tongue to cancer in that part which lies in front of the V should correspond with the presence of organisms which are almost absent on the base behind the V. (c) As m/rt/v/x Sex. Unless a large number of cases are taken, statistics are found to vary very much. There is an enormous preponderance of males, making cancer of the tongue one of the most important of the surgical cancers afflicting men, yet a not unimportant minority occur in women. Doubtless, in some series of cases, the number of women have been very few, only 2 or 3 per cent.; in others, on the other hand, they have reached 30 per cent. Among the 400 cases of cancer of the tongue collected by Jessett, 85 per cent, were males and 15 per cent, females. Whitehead's series of 104 cases contained 15 women. With them also agree Barker's series, 1 5 per cent. ; Gurlt's, 14'6 per cent.; Landau's, 16 per cent. Other series are very different. Czerny's 26 cases, between 1878 and 1888, were all males. Among Kocher's 60 cases were only 3 women. Among Kronlein's 40 cases, 2 women. Wolfier gives 3'4 per cent, of females ; Weber, 12'2 per cent. At the other extreme of variation is Sigel's list, 29 - 5 per cent, of women ; Clarke's, 28 per cent. ; Paget's, 36 per cent. ; Bmn's, 33 per cent. ; and Hayn's, 43 per cent. We may conclude that if a large number of cases of carcinoma are added together, the number of females among them would not differ widely from 15 per cent. The reason for the difference in the liability of the sexes will probably appear in the paragraphs on the cause of the disease. (d) As /vv/r//v/.s Atjc. By far the largest number of cases of cancer occur between the ages of forty and sixty, they being fairly evenly distributed over that period. This means an increasing tendency to cancer between these ages, because the proportion of persons who survive beyond any given 312 DISEASES OF THE TONGUE. year is constantly diminishing a much smaller number of patients remain after sixty to be attacked. Moreover, the predisposing causes of cancer have already come into play ; the influence of smoking and drinking, the results of syphilis, the injuries due to rough and carious teeth, have generally been felt by the tongue long before. The number of cases of cancer which appear after sixty, when the above- mentioned points are considered, forces one to conclude that the general tendency to cancer is as great after sixty as before. Children and young adults are nearly exempt from cancer, which rarely begins before the age of thirty. This is partly to be explained by an absence of the predisposing causes ; at least, these have not had sufficient time to develop cancer. But there are exceptions, and unfortunately very malignant cases have been met with : indeed, none seem to have been cured. Such exceptions may be due to the overwhelming force of some tendency, hereditary or otherwise. This accords with and partly explains that as many cases have been recorded in females as in males, also the virulent course of the disense. Taking those in males first, Variot notes an epithelioma of the tongue in a boy aged eleven, Chappie one in a man aged twenty-four. Two cases are known to Spencer ; in both cancer had occurred in members of the family. A perfectly healthy and ruddy- faced man of twenty-four had a rapidly growing cancer, which was incompletely removed through the mouth, but the surgeon did not securely tie the arteries, and the patient died of recurrent hemorrhage. Another similar man, aged twenty- six, in whom there was no evidence at all of venereal disease, had an indurated, rapidly growing ulcer on the side ot the tongue, the scrapings from which showed well-formed nest-cells. Antisyphilitic remedies had already failed, when at a consultation of the surgeons of the hospital the majority decided that the same measures should be continued, on the ground that the age of the patient negatived the idea of cancer. This was done, but a very rapid glandular enlargement set in, and the patient soon died. Of the female cases, Harrison saw a girl, aged twenty, KMiLY MALIGNANT CANCER. 313 who died in less than six months from the first symptoms. In this case there was no family history of cancer or evidence of syphilis. The youngest patient Butlin has seen was a married woman, twenty-four years old, from whom he removed a very extensive squamous-celled carcinoma of the left side of the tongue, far back, where it grew into the tonsillar region. The glands would have been removed by a second operation, but they were hopelessly fixed and widely spread, so the operation was not proceeded with. In Spencer's case, the patient's father had died of cancer of the throat (? larynx) eight years before, after suffering for two years. The influence of syphilis could be excluded with certainty. She was a ruddy-faced farmer's daughter, aged twenty-two, who had been acting as a schoolmistress in the country. Two months before an ulcer began opposite the left lower molar teeth. The ulcer rapidly extended ; it was not irritated in any way, and the adjacent teeth were removed. In two and a half months from the first sign of the ulcer an epithelioma had involved half of the tongue throughout its length, the floor of the mouth, the surface of the tonsil, and the adjacent portion of the soft palate. The whole of the disease was freely removed with all the glands in the digastric triangle, and healing took place. Some months later, an enlargement of the glands behind the sternoinastoid, in the posterior triangle of the neck, occurred, and she died within ten months of the first commencement of the disease. (hili8 in the production of cancer of the tongue is often raised. With regard to smoking, we may speak more strongly than we ventured to do some years ago. We believe that smoking is a decided cause of the occur- rence of cancer, not so much directly as indirectly : rather by producing or tending to produce those conditions of the surface of the tongue which predispose to cancer, than by immediately leading to the development of cancer in such tongues. We do not rely so much on statistics in support of this view as on our personal experience of individuals suffering from pre-cancerous conditions of the tongue and actual cancer. Thus, Whitehead only found sixty-one smokers among 104 persons suffering from cancer of the tongue, which seems almost a small proportion. But, the common history which we receive of much smoking, the great frequency with which cancer of the tongue is preceded by chronic inflammation of the surface of the tongue, which has occurred in smokers and been main- tained by smoking, and the much greater liability of males to the disease than females, all lead us to this view. Of xi/iiliili*, it may, we think, be said, that in so far as it is capable of producing ulcers and scars of the tongue, so far is it capable of predisposing the tongue to the occurrence of carcinoma. But the ulcers and scars produced by syphilis are not more prone to become can- cerous than the ulcers and scars which are due to any other cause. Nor is the psoriasis (leucoma) or chronic superficial inflammation produced by syphilis more apt to become cancerous than a psoriasis or chronic superficial glossitis which has had no connection with syphilis. But the influence of syphilis is not limited to the power it possesses of producing superficial inflammation of the tongue. It is prone to leave scars along the borders of the tongue, and these, when they are irritated, may at a later period become cancerous ulcers. Even the fissures and scars left by the breaking of deep-seated gummata may afterwards become the seat of carcinoma. Such cases are probably very rare, but an excellent proof of the 316 1HS EASES OF THE TOKGUE. possibility of their occurrence was presented to the London Pathological Society by the late Mr. Morrant Baker. A man, aged forty-seven, contracted syphilis about twenty years before the appearance of the cancer, and about two years later began to suffer from ulceration of the tongue. He frequently attended Baker, at St. Bartholomew's Hospital, thirteen years before, for gumma of the tongue, and about ten years before a water-colour drawing was made of his tongue as a typical case of ulcerating and sloughing gumma. Until a few months before, the disease had always yielded to the administration of iodide of potassium ; but it then ceased to take effect. At the date of the record the epi- thelioma, which had commenced in the scar, had spread beyond the tongue to the adjacent structures and lymphatic glands. Of the application of caustics, we must repeat what was said in the first edition of this book If there be one thing more harmful than another in the treatment of simple indolent sores and affections of the tongue in persons over thirty years of age, it is the application of a strong cau.^fic. Yet the practice of applying it still finds favour in the eyes of a large number of practitioners, and unfortunately secures the approval of their patients, who feel that something is being done for them, and who place great faith in caustics. The practice is one which cannot be too strongly protested against. The result of strong solutions or of solid nitrate of silver on some of the indolent sores remaining on the tongues of children after aphthous ulceration is admirable ; and the same remedy may be employed with good effect in the treatment of some of the indolent sores and fissures resulting from tertiary syphilis in comparatively young persons. - But the use of caustics should be absolutely avoided in the treatment of sores of whatever kind on the tongues of people after thirty years of age. Caustics are not necessary, and the good which they may do is as nothing compared to the cruel harm which they have done to many tongues. So far as affections of the tongue are con- cerned, we should not be sorry if caustics were never again employed in the treatment of any of them. DEVELOPMENT OF CANCER. 317 3. Development of Carcinoma. The first aj>pear. of a Papilloma which doubtless would have soon developed into this rondition. ably to some greater irrigation than usual, a warty growth had formed in the midst of the diseased area. In the first case the growth measured about five-eighths of an inch in its long diameter (which was parallel with the long diameter of the tongue) by one-third of an inch (Plate V., Fig. 3). It stood forth from the surface of the tongue like a small bean, with a slightly papillary or warty contour; it was firm, but elastic, painless, and without induration around its base. There was no ulceration or even excoria- tion of the surface, although, from its situation, it must have been exposed to frequent injury and irritation. In the second case the growth measured nearly an inch by 320 DISEASES OF THE TONGUE. more than half an inch, and its long diameter was, as in the other case, parallel with that of the tongue. It had probably been, not a very long while previously, exactly like the smaller growth, but had become ulcerated, was firmer, and its base was indurated for a short distance in the sub- stance of the tongue (Plate VIII., Fig. 1). Naturally the smaller growth was not watched until it developed into a carcinoma ; but, had it been, it would have slowly been transformed into such a growth as was the second. In all cases of the transformation of warty into cancerous growths, the increase of size, the ulceration, greater, firmness of the tumour itself, and the growing induration of its base, are the principal characters by which the change is announced. (Ct: Fig. 25 with Fig. 24, p. 295.) The least frequent commencement of carcinoma of the tongue is that in which it begins as a lump or nodule in the substance of the organ, or, to speak more correctly, in the tissues beneath the surface ; for although the lump often appears to be situated deeply in the substance of the tongue, and only projects slightly on the surface, there are good reasons for believing that it has originated in changes in the deeper layers of the cuticle. Such a lump or nodule is probably, in many cases, if not in all, carcinomatous from the commencement, and does not become, like the ulcers and warts, inoculated or impregnated with carcinoma. It may, indeed, be said to correspond with the thickening and induration around the base of the ulcer or wart, which has been pointed out as a very significant and reliable sign of the transformation of a simple affection into a car- cinoma. And it is due to the same condition, the in- growing of cylinders of epithelium from the cuticle into the subjacent tissues. But, whatever may be the actual pathology of the lump, the manner of its growth and the characters which it develops are in almost every case the same. It slowly enlarges in the substance of the tongue, is very firm, then projects rather more upon the surface, and finally breaks. When the breaking is accomplished, there is not necessarily a discharge, and the formation of a deep and foul excavated ulcer, although this may occur; but a fungous mass may protrude, or the edges of the VARW11KS OF CANCER. 321 sore may enlarge, become nodular or tuberose, and everted. The leucornatous patches or placqties show clinically the change into cancer by commencing to ulcerate. When ulceration becomes evident the pre-cancerous condition has already passed into the cancerous. Before actually ulcer- ating, a patch which has remained unaltered for years becomes a little more red, a little thicker, its smooth surface is interrupted by pimples or nodules, and a little more discomfort or soreness is experienced. The frequency with which ulceration occurs, and the early stage at which it commences, may be imagined from what has been said. Ulceration is indeed so frequent that it may be regarded almost as a necessary condition ot lingual carcinoma. Probably, the only cases in which ulceration is absent for some long time after the disease is thoroughly developed, are those in which it commences in a warty growth. When this is very papillary and rather dry and hard, it may remain long unbroken, and the car- cinoma may develop in the substance of the tongue. The lump or nodule underneath the surface is also not ulcer- ated at first, and may develop to a considerable size before it breaks down, but it seldom remains unbroken for more than a few weeks. And it has been pointed out in the preceding paragraphs that this is the least common form of development of lingual carcinoma. In the diagnosis of the disease, the frequency and great importance of ulcera- tion will be again adverted to. 4. Varieties of Cancer. The ulijt'i-fii'e characters of the fully-developed disease are very striking, as a rule very unmistakable, and yet widely different in different cases. We have before us four coloured sketches of lingual carcinoma, made by Mr. Godart from cases in St. Bartholomew's Hospital. One of them is of the carcinoma which developed from a warty growth ; it has already been described and needs no further mention. (Plate VIII., Fig. 1.) The second was taken from a case under the care of Sir Thomas Smith. On the left border of the tongue is a large prominent mass composed of several red raw tubers growing from a constricted base, and in a v 322 DISEASES OF THE TONGUE. central depression is a dark greenish grey slough (Plate VIII., Fig. 2). The impression of the whole is of the unfolding of some hideous flower, with its red and fleshy petals turned back, and a horrible mass of corruption hiding its pistil and stamens. Nor is the impression falsified by the foul odour which proceeds from the loathsome weed. For the third we are also indebted to Sir Thomas Smith. The tongue lies at the bottom of the mouth and cannot be protruded, but through the open mouth the whole of the left half of the organ is seen transformed into a raised, warty, and granular mass of irregular form, covered here and there with sloughs or clotted pus, and broken by deep irregular fissures, furrowing it up in various directions (Plate VIII., Fig. 3). In front the disease is limited by the middle line, but not far from the tip it bulges over on to the right half of the tongue. In the last case the dorsum, except where it was actually invaded by the disease, was natural and thickly furred : but in this case the re- mainder of the dorsum is perfectly smooth and equally void of fur and of papillae. The fourth patient was under Butlin's care, who removed his tongue for what is repre- sented in the picture as a disease chiefly of the lett border. It is an oval ulcer without any granulations, but with a smooth glazed surface, which dips in at the centre to form a long and narrow chink. It looks as if the centre were drawn in by some force placed deep beneath the floor of the ulcer. The whole sore is set upon a raised base, over the sides of which the mucous membrane passes to the margin of the ulcer, where it is abruptly limited (Plate VII., Fig. 3). Along the border in front of the dis- ease is a linear superficial ulcer, with irregular notched edges, a simple, indolent ulcer ; and the whole of the dorsum is smooth and pearly or opaque white, without fur, and set here and there with raised warty growths, any one of which might by-and-by become cancerous. Other cases, widely differing from these, yet equally typical of carcinoma, are seen from time to time. For instance, that of a man whose tongue was scarcely more than excoriated at any part, nor was it enlarged. Indeed, it appeared to be smaller than natural, as if shrunken by the disease like a scirrhous breast. It was VARIETIES OF GANGER. 323 smooth and glazed and irregularly furrowed, and almost the whole of the front part was transformed into a hard inelastic substance, almost as hard as wood and almost as unyielding.* So, too, about the same time there was a patient in the hospital, under the care of Mr. Willett, with a very warty epithelioma of the dorsuin of his tongue. The surface was dry and hard, and was at no part ulcerated. The disease might well have been a simple papillary growth had it not been for its indurated base extending into the muscular substance. This patient suffered from typical ichthyosis of the tongue, and the inside of the lips and cheeks, for the surface of all the affected parts was not merely thickened and harder than natural, but decidedly papillary. Another not uncommon form of carcinoma is that in which a deep and foul ulcer is excavated in the substance of the organ. Its edges are usually raised and everted, and nodular or tuberose ; the interior is occupied by slough and discharge and decomposing food ; and the surrounding tissues are infiltrated and indurated. The foregoing instances may be regarded as typical varieties of cancer. There are others which are met with, although less often or only rarely. Double Epithelioma. Two distinct epitheliomas may develop simultaneously upon the same tongue, having between them at first healthy epithelium. A good number of cases are recorded, but the number two has not been exceeded. A simultaneous malignant change goes on in two patches or scars. Diffuse Epithelioma. A patient, the dorsum of whose tongue has been long affected by chronic superficial glossitis due to syphilis and tobacco, instead of having an ulcer at one part, which deepens as it extends, may exhibit a widespread excoriation or very superficial ulceration, accompanied by very slight symptoms. The epitheliomatous change begins simultaneously over the whole of the dorsum of the anterior half of the tongue, and yet has not at the moment extended deeply, although, if not operated upon, the tongue will be * The name of atrophic or fibrous epithelioma is sometimes given to this variety. It deserves more cafeful study than it has yet received, particularly in reference to its origin in syphilis. (See Fig. 30, p. 329, also the references.) 324 DISEASES OF THE TONGUE. covered all over by a malignant ulcer. A microscopic section taken from any part of the dorsum will exhibit down-growing epitheliqniatous columns. Hypertrophic Cancer. Occasionally the tumour projects from the mouth, dragging out the tongue by its weight, and adding to the difficulty which the patient has to take food. It may follow upon syphilitic hypertrophy. It does not present any differences as regards virulence. Epithelioma of the Floor of the Mouth. This form of cancer is liable to be overlooked, as it commences in a fold of the mucous membrane covered in by the tongue. The attention of the patient may not be called to it until it has already spread deeply into the tongue. All that can be seen at first sight is a little nodule, perhaps ; only when the tongue is raised, and the edges of the fold separated, does the disease come into view. It is then found that the disease has spread in depth rather than on the surface, a probe passing deeply into a cavity enclosed by indurated walls. Even the most thorough clinical examination may fail to disclose the whole extent, which can only be guessed at from the increasing pain, salivation, and fixation. If the tongue is dissected after a wide removal, the extent of the disease will generally be found much greater than the clinical examina- tion would have led one to expect. Symptoms. In the earlier stages of carcinoma the most distressing subjective symptoms are usually pain and saliva- tion. The former may be present from the first, may be very sharp or aching or gnawing, and may radiate into the surrounding structures as far as the ear of the same side. Aching pain in the ear is a frequent effect of car- cinomas situated far back on the border or side of the tongue. Salivation is not usually distressing until the disease is more advanced, but in the later stages often greatly aggravates the sufferings of the patient. Neither of these symptoms can be regarded as in any way essential to the presence of a carcinoma; nor, on the other hand, are they proper only to carcinoma ; they are even more common in connection with tuberculous ulcers, and are usually produced by these much earlier than by carcinoma. It is surprising how very painless and free from salivation PATHOLOGICAL HISTOLOGY. 325 some carcinomatous ulcers are, even when they are so situated that they are constantly irritated or injured. It is, however, very unusual for a carcinoma to run its course without producing both pain and salivation in its later stages. 5. Pathological Histology. It has been already stated that the only form of car- cinoma which has been found as a primary disease of the tongue is squamous-celled carcinoma or epithelioma develop- x 8 Fig. 26. COLUMNS OF EPITHELIAL CELLS GROWING DOWNWARDS AND ANASTOMOSING. Reproduced from Butlin's " Sarcoma and Carcinoma," 1882. Plate III., Fig. 6, pp. 130-181. A section of a tongue in which Epithelioma followed Chronic Superficial Glossitis. (Compare Fig. 9, p. 142.) Columns of Epithelial Cells are growing downwards into the subepithelial tissues and -fire commencing to anastomose with one another, x 8. ing from the stratified epithelium of the surface. Glandular carcinoma has occurred in the submaxillary gland, but from the mucous glands on the surface of the tongue no instance seems to have been seen. The minute structure of the disease resembles the minute structure of epithelioma in other similar parts of the body. Columns of epithelial cells (Fig. 26), resembling those of the deeper layers of the epidermis of the tongue, and directly continuous with them, grow down into the fibrous tissue, and through the fibrous tissue into the muscles. Some of the columns grow perpendicularly downwards lor a considerable distance, although they seldom maintain the same thickness and uniformity throughout ; but, as a rule, they diverge, branch, anastomose with one another, and form networks in the deeper structures of the tongue. The columns, or processes, which form these networks are for the most part slender, distinctly com- posed of altered epithelial cells, and enclosed as it were with a single layer of the same kind of cell placed vertically DISEASES OF THE TONGUE. to the tissues (Fig. 27) which surround the column, like the deepest layer of the epidermis, but not nearly so regular or even. The cells of which the columns and various processes of the growing tumour are composed are easily recognised as epithelial, yet they differ in many important respects from the cells which form the normal epidermis of the tongue. They vary considerably in size, and are generally smaller than the cells of the more superficial layers of the epidermis. They vary as much in shape, but are seldom distinctly spindle or caudate. Many of them are frayed out at the borders (Riff-zellen). Most of them are fur- nished with nuclei, which are very large in propor- tion to the size of the cells, and many of them contain two or more nuclei, nucleolated, or are mother cells, filled with two or more secondary cells. These appearances, the regular and irregular division of the nuclei, the vacuoles, the granules, have attracted much attention, and different interpretations have been put upon them (p. 116). The larger columns frequently contain cell-nests or epi- dermic globes (Fig. 28); rounded bodies consisting of one, two, or more altered central cells surrounded by layers of flattened scale-like cells arranged like the scales of a tulip or crocus bulb. Smaller cell -nests may also be seen in the more slender columns, which they sometimes cause to bulge unequally. The columns, or processes, of epithelium are not enclosed in any visible membrane, yet they are almost always clearly separated from the surrounding fibrous or muscular tissues, which are infiltrated with such small round cells as are invariably found in the tissues border- ing on a malignant tumour. With regard to nest-cells, small ones may here and there be seen among the stratified layers of normal epithelium. It y.2oo Fig. 27. GROWING PORTIONS OF EPITHELIAL COLUMNS. From the same source as the preceding Plate III., Fig. 4. From the deeper parts of an Epithelioma of the Tongue showing arrangement of columns of cells, x 200. EPITHELIOMATO I >' A />' T-CELLS. 327 X200 may, however, be mentioned in relation to this circumstance that the microscopic test in diagnosis is not likely to be rendered useless or deceptive by the discovery of cell-nests in scrapings of simple ulcers or of the healthy portions of the tongue : for in the scrapings of more than a hundred tongues, healthy and diseased in various ways, but not carcinomatous, we never have seen anything which resembled a cell-nest. The epithelial cells, too, which are scraped in large numbers from the surface of an epithelioma, are so widely different from the small round cells scraped from other ulcers and from healthy tongues, that there is no reasonable fear that a single cell-nest, even if it should be found, would lead to the belief that the sore from which it came Fig. 28. EprrHEtiojCATOus NEST-CELLS. was carcinomatous. It is not necessary that a nest- cell should be seen in any particular section, although, if several sections from various parts of the growth be examined, some instances are met with. In the soft, vascular, rapidly growing "medullary cancer" masses and columns of cells running along between the muscular fibres are seen with no, or only imperfectly-formed, nest-cells (Fig. 29). A scraping from the surface of such a growth will then only exhibit epithelial cells. The opposite " scirrhous " type above referred to is shown in Fig. 30. It is the small-celled infiltration, especially when this in- vades the epithelial cell-masses, causing degeneration or even suppuration, that makes it difficult to recognise epithelioma un- less well-formed nest-cells are seen (Fig. 31). If only one section From the same source as the preceding Plate lit., Fig. 3. Epithelioma of the Tongue, showing characters of Cells and Cell-Nests, x 200. 328 DISEASES OF THE TONGUE. is examined where the epithelial cells are overrun and obscured by the small round cells, malignant disease may be mistaken for innocent ulceration. If the case is clinically suspicious, the negative result of the examination of one section should lead to the investigation of fresh sections from other parts. Fig. 29. BAPIDLY GROWING EPITHELIOMA WITHOUT NEST-CELLS. "MEDULLARY CANCEK." Photographed from a section of the very malignant case in a young female, under Spencer, mentioned on p. 313. Masses and columns of cells are infiltrating the muscular fibres without forming Nest-Cells. The epithelial cells from an epithelioma could only be mistaken for those in a tubercle. Generally, the nest-cell in the one case and giant cell and central caseation along with the bacilli in the other, are the characteristic features. The cells of a cancer are polygonal epithelium, showing division of nuclei, vacuolation and granules, as distinguished from the flattened epithelial or endothelial cells of tubercle. When, however, the small round cells obscure the main features, and suppuration and caseation occur, more careful examination of several sections is required to distinguish between the two. 6. The course pursued by an untreated carcinoma depends rnntSE <>F r.utn. \H.\I.\. 329 largely on its situation on the tongue. If it commences on the dorsum it extends into the muscular substance, and probably infiltrates a large part of the tongue before it reaches the adjacent structures, or it may never reach them. If it is situated on the border, especially just beneath the Fig. 30. HARD SCIERHOUS EPITHELIOMA. Photographed from a section of a slowly growing form of Epithelioma removed by Spencer, but in which the scarcely enlarged glands were already infiltrated. The columns of Epithelial Cells not showing distinctly formed Nest-Cells are embedded in a mass of newly formed fibrous tissue which has replaced the muscular fibres. border, it infiltrates the tongue, and at the same time makes its way along the floor of the mouth to the gum and jaw. The tongue becomes fixed, and can no longer be protruded or even move much in the interior of the mouth. The bone itself is invaded, grows softer and carious and crumbling, an by-and-by the teeth become loosened and drop out. When the disease commences farther back, it spreads into the root of the tongue, gradually makes its way to the epiglottis, and through it to the larynx ; or, and this is perhaps more usual, it grows into the half-arches of the palate and the tonsil, and may even spread up on to the palate itself, or, burrowing 330 DISEASES OF THE TONGUE. deeply, open the tonsillar artery, or the internal carotid, and so prove fatal. Whatever be the course of the disease within the mouth, if it is left untreated the glands will certainly be diseased. 7. Infection of the Lymphatic Glands. Epithelioma of Fig. 31. EPITHELIOMA. WITH SMALL CELL INFILTEATION. Photographed from a section of Epithelioma developing in the case referred to under Fig. 8. p. 117, q.v. The columns of epithelial cells with nest-cells are in places much obscured by small round cells. the tongue, when not removed, inevitably extends to the lymphatic glands, and this at an earlier period, and to a degree and more widely than is generally obvious to clinical examination. This unwelcome truth has come to be recog- nised by observation of the course of the disease where no operation has been performed, of the great frequency and the early development of glandular enlargement where the whole of the disease in the mouth has been successfully removed, and by careful microscopical examination of glands removed in the course of submaxillary operations. It was a view prevalent among surgeons until recently that a tender- EARLY GLANDULAR INFECTION. 331 ness or soft enlargement of the glands below the jaw and in the neck might be presumed to be due to inflammation, and there was a tendency not to admit a gland to be in- filtrated by cancer unless it possessed a considerable degree of induration. In a doubtful case, it was argued that the glands were unusually well felt owing to recent loss of flesh and thinness of the patient, or because they were pushed towards the surface by the new growth in the mouth. It is now generally admitted that a simple inflammatory enlargement, such as will with certainty subside after removal of the primary growth, is a rare matter. It most definitely takes place in the case of the submaxillary salivary gland when the duct is blocked by pressure of the new growth. Two instances of the kind, Butlin's case and Bloodgood's, are mentioned in the chapter on sarcoma, It may be possible to make out this by palpation, together with the obstruction to the passage of a probe down the duct. But the propriety of removing the primary growth only in a case of epithelioma is contradicted by the fact that an epithelioma, in order to obstruct the submaxillary duct, must have commenced or have spread to the floor of the mouth, and is therefore the most likely of all cancers of the tongue to infect the lymphatic glands early and widely. It is of course true that foul ulceration and decom- position going on in the mouth cause an inflammatory enlargement, or even suppuration, and if the disease is removed from the mouth and healing follows, the glands may subside. Even after an abscess has formed, temporary relief, with subsidence of the swelling, will follow. If, how- ever, an epithelioma has advanced far enough in the mouth to be the cause of inflammation of the glands of the neck, the tendency of all recent observation is to show that the epithelioma has already reached the glands, and the malig- nant growth will continue, although inflammation has subsided. The view as regards the frequency of inflamma- tory enlargement was doubtless favoured by imperfections in diagnosis, inflammatory conditions being more often called cancer than is the case at present ; also, surgeons were content to record the successful results of operations without follow- ing up and publishing the fate of the patient. 332 DISEASES OF. THE TONGUE. In Chapter I. a brief anatomical description has been given of the lymphatic glands in the neck. They were fully described by Sappey, but surgeons have only recently come to make special use of his anatomical work. An indirect means of bringing this about has been the improvement Fig. 32. EARLIEST STAGE OF EPITHELIOMATOUS INFECTION OF LYMPHATIC GLANDS. Photographed from a section of a submaxillary lymphatic gland which, when removed, did not appear enlarged. (Spencer.) If such glands as those slightly swollen, yet not perceptibly so on palpation through the skin, be carefully examined in well-prepared microscopical sections, concentric groups of epithelial cells will be found in the lymph spaces, which are rapidly proliferating and tending to form nest-cells, wliil.it immediately around the lymph corpuscles are increased in number, but the rest of the gland normal. in the surgery of the breast which has followed from an increased knowledge of the lymphatics and lymphatic glands infected by mammary carcinoma. Yet these successes are only suggestive of what may be accomplished in the case of the tongue, for there is no strict analogy between the two the one concerns a glandular cancer and the other an epithelial one. The epithelial carcinoma apparently does not lodge in the lymphatic vessels, but the cells are thought to pass, like emboli, to the lymphatic glands, an important factor to which Heidenhain has drawn attention. At first sight the anatomical account of the lymphatics and glands connected with the tongue does not seem to aid surgery, GLANDS INFECTED BY CANCER. 333 when one learns that an injection into almost any part of the muscular substance of the tongue or underneath the mucosa of the floor of tho mouth is followed by the spread of the injection to the glands in all directions. Indeed, a contemplation of his anatomical observations, in which he confirms those of Sappey, has led Ktittner to propose as the regular operation a reflection of the skin on each side of the front of the neck and the removal of all the lymphatic glands from the area bounded by the jaw and mastoid process above, the sternomastoid behind, and the sternum and clavicle below. Whilst such a dissection may be surgically possible and even reasonable in a few patients, it cannot be generally applied ; indeed, it is out of the question in many cases. Whilst it is now well known that removal by the mouth, together with excision of glands which are felt to be enlarged, is very often insufficient, yet the difficulty is to say how far the dissection of glands not obviously enlarged should be carried. This is a question which further clinical observa- tion can alone decide. Roughly speaking, cancers of the tip of the tongue infect the submental glands (Fig. 7), those of the middle of the tongue and floor of the mouth, the sub- mental, submaxillary, and carotid glands, those of the base of the tongue, the upper and lower deep cervical glands (the parotid and carotid groups). But experience shows that this generalisation is very imperfect from a surgical point of view. It is the chain of the deep cervical glands, which lie generally in front of the internal jugular vein, and over- lapped by the anterior edge of the sternomastoid, to which attention must be directed; especially the lower glands of this chain, which are placed over the bifurcation of the carotid, at the level of the thyroid cartilage (the carotid group). These deep cervical glands extend upwards to the base of the skull, and downwards below the crossing of the omohyoid muscle. It is not a question of one " carotid gland " which becomes infected, but of a chain. But, although the entire chain may be infected, the glands at the bifurcation of the carotid are often the first and the most infected, as one of the large efferent vessels runs directly down to them. 334 DISEASES OF THE TONGUE. Malignant infiltration of the sublingual salivary gland is the result of direct extension. The subrnaxillary salivary gland may be infected in the same manner, but infection commonly spreads into it from lymphatic glands which lie within its capsule, before any direct extension to it has taken place. Goldmann believes the veins may be a source of infection. The lymphatics, after passing through the deep cervical glands, enter the jugular veins. But he believes also that the veins leaving the tongue and floor of the mouth may be channels of infection to the submaxillary and parotid salivary glands. We do not know on what evidence this opinion rests. As a rule, early infection of lymphatic glands is unilateral, when the primary growth is itself strictly unilateral and limited. A bilateral infection is, as a rule, observed only when the growth extends beyond the middle line, although the glands on one side may be in a more advanced stage of disease than those of the other. But the unilateral character of the infection does not hold for the later stages. The glands on the opposite side often become infected and enlarged before the case terminates. Again, a growth which approaches the middle line may infect the glands on the opposite side even to a greater extent than on the same side. Even worse, a small and limited epithelioma, far back on one border of the tongue, is occasionally associated with affection of the glands on both sides of the neck, or on the opposite side alone. If, however, the rule as regards unilateral infection be strictly limited to the early stages, and only to those growths which do not approach the middle line either on the surface or insidiously in the deep substance, then the exceptions will be found to be very few. The appearance of a lymphatic gland markedly infected with epithelioma does not differ from that of the primary growth. On cutting across the enlarged gland the section shows whitish nodules or masses, which may be sofc and breaking down in the centre, or of various degrees of hardness, even so fibrous as to creak under the knife. Sections examined microscopically show masses of epithelial cells with the peculiarities above described ; also often, but not invariably, LATER STAGES OF GANGER. 335 nest-cells, one or more in a section. In some cases the glands become actually cystic and fluctuate. They are full of clear or turbid fluid, but the wall of the cavity is cancerous. It is otherwise with glands in the earliest stage of the infection. Then they may be so soft and small as not to be felt until the fibrous tissue covering them has been divided. They appear only slightly enlarged, or, if markedly so, still soft and vascular; but the simple or smallest compound glands appear more numerous than in an ordinary dissection, because they are rendered prominent by the com- mencing infection. On cutting a somewhat swollen gland across, one or more minute white points may be seen, or several small haemorrhages, which, when the gland has not been roughly handled in removing it, are suspicious signs. The careful examination of a number of microscopical sections from several such glands will show many spots where a new growth of epithelioma is beginning and nest- cells forming, embedded in the lymphadenoid tissue of the gland (Fig. 32). Of course, the examination of any one section from a gland may be negative, and it is only from a number of sections from many glands that a correct idea of the extent of glandular infection at the time of the operation can be estimated. 8. The later Course and Termination of Cancer. In every case which we have seen or read of in which no operation was performed, the glands were affected. The disease is not really limited to the parts which are first and most markedly affected, but has spread, perhaps very deep down, through the adjacent parts without altering them to such a degree that the alteration can be discerned by sight or superficial touch. The affected glands are at first small and hard, and freely movable, but as they increase in size grow softer and are less movable, until at length they may distinctly fluctuate, and are quite im- movable. Sometimes they form an enormous mass on one or both sides of the neck. The mass may partly suppurate, and gradually form a deep chasm lined by foul granula- tions and gangrenous pieces of new growth, or, still more strange, after remaining for a while open and discharging, 336 DISEASES OF THE TONGUE. heal up and shrink to a fibrous mass, but never entirely subside. It would be a great advantage if it could be shown that the glands are never affected during a certain definite period after the first appearance of the disease within the mouth ; if, for example, it could be laid down as a law of carcinoma of the tongue that affection of the glands never occurs within six months after its first appearance. Unfortunately, this cannot be done. In some reported cases the glands are said to have been enlarged at the time the disease was first noticed in the mouth, and although it is in the highest degree improbable that carcinoma was developed in the tongue and the lymphatic glands simultaneously, there can be no doubt that affection of the glands does sometimes occur extremely early so early, indeed, that the disease is only recognised as carcinomatous by the enlarge- ment of the glands which is associated with it. It is probable that in the most rapidly progressive cases the glands may be affected within a few weeks after the disease in the mouth has become actually carcinomatous. On the other hand, there, is quite as good reason to believe that carcinoma of the tongue may exist for six, or possibly even more months before the glands are involved. As the disease advances, speech and swallowing become more and more embarrassed. When the tongue is bound down to the floor of the mouth, and there is profuse saliva- tion, it is extremely difficult to understand what the patient says. The acts of swallowing after the food has made its way to the back of the mouth are usually accomplished without difficulty, but the collection of the food from the sides of the mouth and the massing of it into a bolus are impossible, on account of the immobility of the tongue. Fluids and such soft and coherent solids as jellies are, therefore, more easily disposed of than solids which are masti- cated. The later stages of the disease are not infrequently complicated by ha3morrhage from vessels opened by the progress of the ulceration ; the haemorrhage may be arterial or venous, and even capillary bleedings may be frequent and troublesome. But death from haemorrhage, in cases which are not treated by operation, is not by any means the most DISSEMINATION OF GANGER. 337 frequent termination. The large majority of patients die through slow exhaustion, increased in some cases, no doubt, by repeated small bleedings. The exhaustion is due to several causes ; to pain, to profuse salivation, inability to take sufficient food, sleeplessness, suppuration, and, in some instances, sloughing of the cancer. And when the patient is in a state of extreme exhaustion, the final blow is some- times administered by a low form of pneumonia, which is much more commonly observed in those who die after removal of the disease. It is to be lamented that haemor- rhage is not a more frequent cause of death than is actually found to be the case, for the sufferings of those who die of cancer of the tongue, whether without operation or with recurrence after operation, are in most instances severe. Patients who are not operated on usually die within a year or eighteen months after the first appearance of the disease ; or, if an ulcer has existed for years upon the tongue and has become cancerous, within a year or eighteen months from the time at which the alteration in its char- acters was observed. The shortest duration of life of which we have any record was in an old and feeble woman of seventy-eight years, who died five months after the first appearance of disease within her mouth. The large majority of the unoperated die within twelve months. 9. Dissemination. This in connection with carcinoma of the tongue is a somewhat rare event. Whether it be that patients die too early for the occurrence of dissemination (a very improbable suggestion, when the rapidity of the dissemination of some sarcomas of bone and of some carcinomas of the breast is remembered), or whether the channels through which dis- semination can occur are not easily available (a suggestion not more acceptable than the first, when the situation of the disease and the great vascularity of the tongue are considered), or whether squamous-celled carcinoma origi- nating in the tongue has very little tendency to strike root and grow in any other organs than the tongue and glands, or whether the cells travelling like emboli along the lym- phatics are nearly always caught in the meshes of some lymphatic gland and do not reach the veins, the fact remains w 338 DISEASES OF THE TONGUE. that dissemination of the disease rarely takes place. Yet it is possible that it may occur more frequently than is now supposed, for the number of post-mortem examinations of persons who have died from the disease, either unoperated or after recurrence, is small, so that very large conclusions must not yet be drawn upon the subject. It might be thought that the lungs would be more frequently affected than any other organ, on account of the relation which they bear to the part primarily affected. Material may be carried into them by the inspired air or through the medium of the blood. But experience, that is, the experi- ence which we possess at present, shows that the liver is affected as frequently as the lungs, in some cases with the lungs, in some cases alone. If this rule proves, after more extended investigations, to be correct, it can only be sup- posed that the tissue of the liver affords a more suitable soil for the planting and development of the disease than the tissue of the lungs. Fere met with three nodules of epithelioma, the size of large peas, in the wall of the right and left ventricle of the heart. The man was aged sixty-four, was a great smoker, and suffered from ulceration of the tongue for some months, and there was enlargement of the submaxillary and sterno- mastoid glands. The tongue was removed, and a growth immediately recurred on the stump. There was extension in the neck, and death followed four months after the operation. A woman aged fifty-five, under Hutchinson, was found to have epithelial cancer in the lungs and bronchial glands, In Godlee's case the development of secondary growths was most unusually extensive. The primary growth was a small hollow epitheliomatous ulcer on the left side of the under surface of the tongue. There were minute nodules of growth in the skin covering the left half of the thorax and abdomen, a mass at the root of the neck had perforated and destroyed the manubrium sterni, and was continuous with a growth in the anterior mediastinum. It was not a separate glandular enlargement, but an enormous spreading mass, obliterating the left innominate and jugular veins. Nodules, the size of a pea, were found in the sub-serous tissue of the CARCINOMA A LOCAL DISEASE. 339 lungs, also in the substance, and the left apex had been directly invaded from the neck. Nodules were found on the surface of the liver, in the cortex of the kidney, and in the heart, in the sub-serous tissue of the diaphragm, and in the supra- renal capsules. Both the larger and smaller growths were tending to break down in the centre. Secondary or Metastatic Cancer of the Tongue (?). In MacCormick's case the disease of the tongue was considered to be secondary to that of the breast. In a woman, aged thirty-six, the right breast was affected with scirrhus, and was removed along with the axillary glands. Three months later a pimple was noted, which rapidly grew to a lump in the middle of the right side of the tongue, one inch in diameter. The tongue was removed well beyond the lump, and microscopic examination proved it to be of a " scirrhous nature." Within a year of the breast operation there was enlargement of the submaxillary and deep cervical glands, which were dissected out, and the patient recovered from the operation, but nothing was said about the microscopic examination. It is seen that the case is by no means clearly demonstrated by the account, and it is not unlikely to have been a primary growth in the tongue, just as a case of Whitehead's had had an epithelioma removed from the Up nine years before. We think it may be accepted for the present, at least, that carcinoma of the tongue is essentially a local disease, certainly not limited to the part in which it takes its origin, but yet surely to that part and the immediately adjacent parts, and to the neighbouring lymphatic glands. It may cover a wide area, yet it is so far local that in the large majority of instances, if these parts to which it spreads, either directly or through the medium of the lymphatics, were com- pletely removed, a cure of the disease might confidently be expected. The more limited the area involved in the disease, the more easy and the less dangerous is it to fulfil these conditions ; the more widely spread the disease, the more difficult, the more dangerous the operation, until complete removal becomes incompatible with the recovery of the patient. Under these circumstances, the importance of an early diagnosis cannot be over-estimated. If an operation 340 DISEASES OF THE TONGUE. is to present a good chance of complete success, it ought to be performed before the disease has extended far back in the mouth, and certainly before the glands have become enlarged. For, although cases are recorded in which com- plete recovery has followed operations on very extensive lingual carcinomas, such cases are very rare. And still more rare are those in which complete recovery can be claimed after removal of the primary disease and associated glands. Assuredly no cases so advanced as these can be said to offer a good prospect of complete recovery. 10. Diagnosis. The diseases most likely to be mistaken for carcinoma are syphilitic lumps and sores, tuberculous ulcers, simple warty tumours, and simple ulcers and fissures. The resemblance which each one of these diseases at times bears to carcinoma is so great that the difficulty of deciding on the exact nature of the affection is extreme. And it is increased especially by the fact that certain of these diseases are transformed into carcinoma, and the transition is very gradual and by almost imperceptible gradations. Secondary syphilitic affections are scarcely ever mistaken for carcinoma, but primary and tertiary affections may both closely simulate it. A primary sore upon the tongue is so rare that the question between it and carcinoma will very seldom arise. It is more likely to occur in younger subjects ; it may occur as frequently in women as in men ; and it occurs usually at or near the tip of the tongue, while car- cinoma occurs almost always farther back along the border. The glands are enlarged from the first, or very early ; and, at a period of the disease at which few persons would be inclined to operate, secondary symptoms always appear. The conditions of tertiary syphilis require to be distinguished from carcinoma, the unbroken gumma, and, far more fre- quently, the ulcer left by the breaking of the gumma. The only form of carcinoma for which the unbroken gumma can be mistaken is that in which the disease commences as a lump or nodule in the parts beneath the mucous membrane. Both conditions occur for the most part on the dorsum ; in both cases the lump is at first ill-defined, firm, and intimately associated with the tissues of the tongue ; in both the DIAGNOSIS OF CANCER. 341 progress of the disease is at first slow, and there is no affection of the lymphatic glands ; both affections occur more often in men than women, and more often in adults over thirty years than younger. The points of resemblance between the two diseases are many and striking; indeed, we believe it is sometimes impossible to distinguish between them. But the following points in which they do or may differ should be borne in mind. It is not unusual to observe two or more gummata in the same tongue, while it is extremely rare to observe a second carcinoma. There are not infrequently old scars of syphilis upon the tongue, and associated signs of syphilis in other parts of the body, and there may be a clear history of syphilis. The cancerous lump is not un- commonly associated with a diseased condition of the surface of the tongue, with leucoma or chronic superficial glossitis. On the other hand, it must be remembered that these con- ditions may be the result of syphilis, and that carcinoma may occur in old syphilitic tongues. It is almost certain, in such doubtful cases, that the effect of treatment will have been tried. The question of diagnosis between a carcinoma and a gummatous ulcer is far more often raised on account of the great frequency with which carcinomas ulcerate, and although the resemblance of one disease to the other is often very close, we do not think there ought to be nearly so great difficulty in distinguishing them. ' Guinmatous ulcers are often met with in the central parts of the tongue, cancerous ulcers chiefly at the borders ; the edges of guin- matous ulcers are usually undermined, those of cancerous ulcers are raised, nodular, and hard ; gummatous ulcers are much more often multiple than cancers ; gummatous ulcers are rarely so deeply or so widely indurated as cancers; and the lymphatic glands are scarcely ever affected in tertiary syphilis, whereas they are almost invariably, enlarged in connection with cancerous ulcers which have existed long. We have purposely mentioned this condition last, and have entirely omitted any statement of the results of anti-syphilitic treatment, because we are firmly convinced that the diagnosis ought to be made in all but the rarest cases long before the glands have become affected, and because we are just as strongly of opinion that the test of treatment ought 342 DISEASES OF THE TONGUE. never to be applied in any but the earliest stages of the disease. In all cases in which there is actual ulceration, and the question is raised whether the ulcer is carcinomatous, the microscopic test should be applied, and a portion of the wall of the ulcer should be removed, cut in sections, and carefully examined. A likely part of the ulcer is selected, a pledget of cotton- wool soaked in a 20 per cent, cocaine solution, applied for three minutes, and then a small fragment cut off. This can be hardened very quickly in absolute alcohol embedded in paraffin, and cut in serial section, so that not a bit of the piece is lost, and the whole series of sections can be examined. If time presses, quicker methods may be adopted : the piece may be boiled in a test-tube, sections cut with the freezing microtome, and quickly stained. If the result of the examination is negative, and yet the case is clinically suspicious, another piece should be cut away for re-examination. The first piece cut away may be a mass of inflammatory granu- lations where the small round cells have overrun and obscured the epithelial growth (Fig. 31). This method of examination should be employed in every doubtful case. It can be used in most instances with success, even when there is no ulceration. The reason which leads us to speak so strongly in favour of the microscopic examination is that we have seen many cases in which carcinomatous ulcers have been treated as syphilitic ulcers by some of the best clinical surgeons in London, not because they felt sure that the disease was syphilitic, but because they could not feel sure whether it was cancerous or syphilitic. Weeks were allowed to lapse in this manner, until the ulcer had clearly shown that it was not in the least affected by anti-syphilitic treatment, and perhaps had implicated the lymphatic glands. The period at which it should have been removed was allowed to pass, and the operation was undertaken when the prospect of ultimate success was exceedingly small, and when the patient was weakened by the use of large doses of iodide of potassium, and, in one case, by mercurial salivation. The diagnosis between tubercle and carcinoma is, in many cases, even more difficult than between syphilis and CARCINOMA AXD TUBERCLE. 343 carcinoma, but the more widely-spread knowledge of tuber- culous ulcers which prevails now than formerly has rendered the number of mistakes in diagnosis fewer. Primary tuber- culous ulcers of the tongue are rare, and the associated signs of tubercle in secondary ulcers ought to suggest the gravest doubts of carcinoma, even when the symptoms are in other respects suggestive of it. In the section on tuberculous ulcer the diagnosis of carcinoma and primary tuberculous ulcer is discussed, and it is there mentioned that all the primary tuberculous ulcers described and ex- amined by Nedopil had been cut out, under the impression that they were cancerous. To this we may add that the manner of dealing with them thus summarily was the best that could be devised, both for tubercle and cancer, and if the same decisive method were adopted in the case of all doubtful ulcers of the tongue, there would be a striking diminution in the number of deaths from lingual carcinoma. The difficulty of distinguishing a carcinomatous from a simple warty growth is greatly increased by the fact that the latter usually passes slowly into the former. The disease begins as a simple warty growth, and the warty growth after a time becomes almost imperceptibly a carcinoma. It has been already pointed out that the softer growths almost invariably ulcerate, and that both the softer and the harder warts become more fixed upon the tongue, while the base and the surrounding parts become indurated. And we know no surer signs than these conditions of ulceration, fixation, and induration, of the malignant change which the innocent disease is undergoing. The same difficulty which attends the diagnosis of a warty growth is met with in distinguishing between a simple ulcer and a carcinoma, for the former passes slowly into the latter, and the exact period at which the transformation is accom- plished is not marked by any certain and clearly discernible sign. The age at which the ulcer occurs, the extent and intensity of the surrounding induration, and especially the increase of induration, may do much to make the diagnosis plain. And the fact that the ulcer remains stationary, or actually increases after the cause which produced it has been removed, is another important sign. But, with all care, it 341 DISEASES OF THE TONGUE. not infrequently happens that a simple or traumatic ulcer has already for a long time been carcinomatous before the fact is appreciated ; and it is only when the lymphatic glands are decidedly enlarged that the suspicion of the change is turned into certainty. A microscopic examination in such cases should be made from time to time. Cancerous Fissures. It is extremely difficult to diagnose the case when the disease consists in a narrow indurated fissure. The fissure may extend much deeper than appears at first sight, and must be examined by the separation and lifting apart of overhanging edges. The large amount of small-celled infiltration may allow of a small piece being cut or scraped away for microscopical examination without yielding any characteristic appearances. Supposing the disease to be unaltered by syphilitic remedies, both local and general, it is almost certainly either epithelioma or tubercle, exceptionally actinomycosis, or has formed around a foreign body or calculus. In all these cases a local excision of the indurated fissure is indicated, and the question of dealing with the glands can be left until the excised mass has been thoroughly examined. Carcinoma in the floor of the mouth has to be distin- guished from a calculus embedded in the subrnaxillary or sublingual glands or ducts. Much painful induration covered with foul granulations is met with in both cases. The diagnosis is made by striking the calculus with a needle or exposing it by an incision. The cases in which a calculus has been thus found in the centre of an inflammatory mass have not been diagnosed until the exploration undertaken at the commencement of an operation. The only mistake likely to be made would be to commence an extensive sub- maxillary removal of glands before the exploration of the tumour in the floor of the mouth. Even if it is necessary to excise the inflammatory mass, owing to the gland being destroyed, this will be a much more limited operation than that necessary in the case of epithelioma. With regard to the general subject of the early diagnosis of carcinoma of the tongue, we are glad to believe that the attention of the profession and of the public is much more keenly directed to the importance of it than was the case EARLY DIAGNOSIS OF CANCER. 345 even a few years ago. I 'mil tin.- last few years the practice was almost universal in the profession to regard a carcino- matous uk-or as probably, then possibly, an ulcer of some other kind until it was very clearly proved to be a i-aivinoma by unmistakable signs, such, for instance, as the implication of adjacent structures, the adhesion of the tongue to the floor of the inouth, and the enlargement of lymphatic glands. We do not mean to say that all the cases which \\riv seen by surgeons of large experience attached to hospitals were treated in this fashion ; yet even among them there was a fatal tendency to do what is commonly termed "give the patient a chance," by treating the disease on the assumption that it was syphilitic or simple. Gradually medical men are coming round to the belief that to "give the patient a chance " means, under such circumstances, to " give the carcinoma a chance " of obtaining a firm and irresistible hold, and to take all chance of complete recovery from the patient. Without doubt the tendency which now prevails among surgeons to operate early, and even in doubtful cases, depends in large measure on the greater knowledge which we have of good and safe methods of removing the whole or a part of the tongue. The operation, especially when only a segment of the organ is removed, is no longer regarded as a very difficult or very dangerous opera- tion. Owing partly to this circumstance, partly to the fact that practitioners of all kinds are beginning to recognise the extreme danger of delay in doubtful cases, we have observed a growing disposition to recommend the removal of what would formerly have been regarded as insignificant warts and lumps and sores. An almost trivial operation is practised, and the fear, nay, sometimes almost certainty, of a horrible death from lingual cancer is averted. There is only one prognoxi* in all instances of unoperated lingual carcinoma, death ; and we are sorry to say that the prognosis is the same for a large proportion of cases treated by operation when the characters of the disease are im- uiistakeable. The manner of death, and the duration ol the disease, in unoperated cases, have already been dis- cussed, and it now remains to consider the value of operation as a means of saving or prolonging life, or of saving pain. 346 CHAPTER XIX. EAKLY SURGERY OF THE TONGUE. The Diagnosis of Epithelial Cancer and the Early Classical Operations Summary of Early and Classical Operations (n) Before the Sixteenth Century ; (A) In the Sixteenth and Seventeenth Centuries ; (e) In the Eighteenth Century ; (rf) The commencement of the Nineteenth Century ; (e) The beginnings of Present- day Operations : C. J. M. Langenbeck, Cloquet, G. Mirault, Jaeger, Regnoli, Roux, Sedillot, Guthrie, Syme ; (f) flcraseur Methods : Chassaignac's Chain ficraseur, Nunneley's Galvano-Ecraseur, Morrant Baker's Whipcord Ecraseur : (g) Dieffenbach, Demarquay, Hilton ; (h) Whitehead's Method and its Fore- runners () Kocher's Operation and previous Operations by Billroth and B. v. Langenbeck ; lodoform Dressing. THE diseases of the tongue received little attention until this century ; indeed, they seem to have been scantily treated, out of proportion to the medical knowledge of the time. From this it might be conjectured that diseases of the tongue are now relatively more common than they were in former days. Perhaps the extension of syphilis at the end of the Middle Ages and the introduction of tobacco into Europe may have produced a great increase. It is in accordance with this that we find the earliest and clearest description of cancer, as distinct from vague accounts of scirrhous ulcers and tumours, by Wiseman, in his " Chirurgical Trea- tises," 1676. He describes two cases, one of an army officer, the other a man, aged sixty, both with a fungating growth in the mouth and enlarged glands, of which they shortly died. After describing how he burnt down the fungating growth with the cautery and so gave temporary relief, he says, " That the cure succeeded not, must be imputed to the greatness of the disease, and may teach others how dangerous it is to neglect the consulting the experienced chirurgeon while the disease is recent and easy to be eradicated." In following up the gradual emergence of cancer from DIFFERENTIATION OF CANCER. 347 among other conditions, we must recognise that it was not until the middle of the century that syphilitic con- ditions began to be clearly differentiated from it. Thus, if we read the papers by Ferguson (1801), Earle (1823), Travers (1829), we do not find any definite distinctions between syphilis and cancer. It must have been very difficult before the introduction of iodide of potassium, as the free exhibition of mercury led to a further confusion in the diagnosis by setting up acute glossitis. There is a paper by Majendie, published in 1828, with the title, " Ulcerations anciennes de la langue et du pharynx gueries par 1'hydriodate de potasse," but the use of iodide of potassium was not general until ten years later. When it was adopted, the administration of mercury was by some dropped altogether. By thus treating the earlier stages of syphilis imperfectly, another hindrance to correct diagnosis may have resulted. This brings the matter up to the time when began the microscopical examination of the growths. Sir James Paget, in his " Lectures on Surgical Pathology," 1847 1852, lecture xxxii., Epithelial Cancer, says in one footnote : " I described the papillary origin and construction of these cancers in 1838" (Medical Gazette, xxiii., 284). In another footnote : " \Ve owe the ability to interpret these appearances, which illustrate many things interesting in the general physiology of cells, almost entirely to Virchow (in his Archiv, iii., 97) and Rokitansky (in his Pathologiscke Anatomie, Bd. i.)." With regard to the early and classical operations it is not easy to compare them, for they were not all done for cancer; some were certainly not cases of cancer at all, others are very doubtfully so. Thus Pimpernelle, who died in 1658, cut away a tongue which had become gangrenous following apparently mercurial glossitis. Many of the so- called cancers were very minute. Home removed by the ligature en masse method one which was the size of a pea, and about which he first had a consultation with Cline. Several of the early operations were cases of lymphangioma and macroglossia in young girls and boys, existing for many years or dating from birth. As late as 1839 Arnott termed a case of this kind malignant, but it was not what 348 DISEASES OF THE TONGUE. we mean now by cancer; it was, from the description, a congenital lymphangioma of the left side of the tongue in a girl aged fifteen, and other earlier cases will be mentioned by Hoffmann, Biittner, Bieshaar, Siebold, Mirault (father and son), and Regnoli. As regards a clear distinction from syphilis and the confirmation of the diagnosis by microscopical examination, the description of Syme's classical case is lacking. Syme had lost his first two cases in 1857 and 1858, and became for the time an opponent of the operation ; when, in 1865, a man, aged fifty, who had suffered with his tongue for many years, especially the last three, presented himself, with his tongue swollen, indurated, tuberculated, and brown like the back of a toad and fixed in the floor of the mouth. The tongue was removed by the method introduced by Sedillot in 1S44. The lower jaw was divided and the tongue cut away with . the knife as far back as the hyoid. But Syrne's descrip- tion does not inform us about any ulceration or special signs of cancer, nor as to the naked eye or microscopical description of the material removed. The major operations on the tongue, except for a few exceptions, were not performed until within the last five- and-twenty years. Until decomposition in the mouth and septic infection were prevented by the discovery of anti- sepsis, an operation on the tongue was a very hazardous feat. When operations for rnacroglossia in healthy young people were followed by fatal sloughing and septicaemia (e.g. Siebold's case, from which the figure of the lower jaw on p. 271 is taken, died at the end of a month; Listen's case died of pyaemia), what was to be expected in a patient exhausted by cancer ? In the following summary of early operation the original sources have been again referred to. There was a curious error in the previous edition, copied through Holmes' " System of Surgery," from Wolfler's paper. Just, the earlier writer, is correct on the matter. The date of Guthrie's paper, 1856, got changed somehow to 1756, and so Wolfler concluded that Guthrie was the first English surgeon to remove the tongue. The reference is to the case published in the Medical Times and Gazette of June 21st, 1856, after BEFORE THE SIXTEENTH CENTURY. 349 his death, operated upon by G. J. Guthrie, the distinguished Peninsular and Crimean surgeon, who was born May lst ( 1785, and died May 1st, 1856. This is an instance of the difficulty of maintaining accuracy in matters of medical history. () Before the Sixteenth Century. Hippocrates, as regards the tongue, chiefly treats of the clinical signs- of general disease which it exhibits. He also recommends bleeding from the lingual veins, the opening of an abscess at the base of the tongue by a bistoury guided by the finger. He speaks of cancer exulceratus, and the value of the cautery when other things would not cure. He also men- tions a case in which the tongue was affected, following disease of the base of the skull. The general view of cancer is summed up in the aphorism, "It is better not to apply any treatment in cases of occult cancer, for, if treated, the patients die quickly ; but, if not treated, they hold out for a long time." Second and Third Centuries. Galen mentions a case of simple or muscular macroglossia, as quoted on p. 275. His " Humoral Pathology " is said to have prevented the active treatment of malignant ulcers for a long period. He believed that cancers were due to black bile, and that all ulcers due to black bile were incurable. Celsus gives the account of "Diseases and Surgery of the Tongue," which was copied without being added to by subse- quent writers. In lib. vi., cap. xi., is an account of ulcers of the mouth and of thrush ; in cap. xii. the bland treat- ment of ulcers of the tongue, etc. ; in cap. xv. an account of gangrenous ulcers of the mouth and tongue which, when simpler means did not cure them, were to be cauterised or excised. Lib. vii., cap. xii., paragraph 4, describes the divi- sion of the framum, after seizing the tongue with a volsella, taking care to avoid hemorrhage. He knew of a case in which no improvement in speech followed. Paragraph 5 describes abscess and ranula under the tongue. Fifth Century. Caalius Aurelianus recommended scarifi- cation for enlarged tongue, and the other methods mentioned on p. 274, which caused so much suffering, were also generally employer). 350 DISEASES OF THE TONGUE. These are the limits within which the surgery of the tongue was confined. Seventh Century. Paul of Aegina used an instrument for controlling haemorrhage from the tongue. Tenth and Eleventh Centuries. Albucasis, or Abulkasim, the Arabian. The surgery of Albucasis deals only with : Division of the fraenum, extraction of ramila, and the application of the cautery to early cancer. (b) In the Sixteenth and Seventeenth, Centuries. Fabricius ab Acquapendente, in the chapter on the surgery of the tongue, treats of: Depression of the tongue by a spatula, the fur on the tongue, the division of the framum, anent which he deplores the custom of midwives, who, as a matter of course, tore through with a sharp finger-nail the framum of an infant as soon as it was born (p. 31) ; also ranula, in which he follows Celsus. Ambrose Pare made the first advance after Celsus by mentioning three cases two in boys and one in a man of the successful application of immediate suture, so that union was obtained of pieces of the tongue nearly bitten off by falls upon the chin. On the other hand, he not only advised division of the framum, but also the further tearing by pushing the tongue upwards and backwards with the finger a method which has proved fatal to many children. For ranula he used the cautery in preference to the scalpel. When Fabricius Hildanus was called into consultation on the case of a man, aged sixty-six, who had a cancerous ulcer of the left side of the tongue, he directed the treatment towards counteracting the supposed cause the " black bile " of Galen. The caustics which had been applied were stopped, and the patient improved for a time, but afterwards caustics were again used, and he got worse. Excisions now began to be practised occasionally. It has been mentioned above that Wiseman used the cautery in two cases of undoubted fungating cancer. Surgeons at this time must have been well acquainted with the results attending the barbarous punishment intended to prevent free speech by cutting, burning, or tearing off the projecting portions of the tongue (p. 52). Many recovered, and SEVENTEENTH AND EIGHTEENTH CENTURIES. 351 were able to speak well afterwards. Cases of ill-developed tongues were recorded in which there was good speech (p. 27). But also there were numerous cases of gangrene of the tongue after smallpox (p. 76), and in venereal disease as a consequence of the free administration of mercury. Louis speaks of the frequency with which this occurred in the Military Hospital at Metz, where venereal disease was treated by mercurial inunctions to salivation Pimpernelle, who died in 1658, cut away the gangrenous half of the tongue which had followed the use of mercury. Healing followed, and the patient spoke well. Walaeus cut off successfully the superfluous portion of the tongue from a case of macroglossia. The girl was a patient of Bartholin's, and her tongue protruded a hand-breadth from her mouth. Petrus de Marchetti, in 1664, excised by cutting and burning a tumour the size of a hazel nut, situated under the tongue in the position of ranula. The tumour was hard, but fleshy ; it was not hollow, nor did it contain any substance. De la Motte, in 1685, ligatured with silk the pedicle, which was as thick as the little linger, of a tumour growing on the tip of the tongue. Yicary, the surgeon to Edward VI. and the Queens Mary and Elizabeth, has, in " The Surgeon's Directorie," a great number of local remedies for " canker of the mouth." (c) In the Eighteenth Century. There was no appreciable advance with regard to the surgery of the tongue during the eighteenth century beyond the stage already reached. Petrus Menonista (of the sect of the Menonites), a surgeon of reputation, cut away an ulcerous hardness which had recurred after a previous excision with a curved bistoury, and applied the cautery, whilst Ruysch held out the tongue with a piece of linen and guarded the cheek with a wet cloth. The patient was an old woman, and the growth did not return. Marescotti, of Modena, also successfully cut oft* a large cancerous ulcer from the left side of the tongue. Heister, of Helmstadt, excised a scirrhous cancer with a scalpel, whilst an assistant held out the tongue. 352 DISEASES OF THE TONGUE. But he said that the disease must be cleanly extirpated, otherwise it would rage worse than before. In order to do so, it was necessary to remove some of the sound parts of the tongue also. Buxdorf used scissors instead of a knife for the extirpa- tion of a cancer from the right half of the tongue of an old man, which he did by drawing out the tongue with forceps and cutting it out. He arrested the hemorrhage by applying ice and the cautery. In consequence of a delay in healing, he applied the cautery again three times, and healing only occurred after four months. Five months later there was recurrence in the parotid and sublingual glands. Cases of macroglossia are also recorded. Hoffmann, of Stockholm, excised the projecting portion of the tongue from a girl aged ten. The tongue had been too large from birth; it projected four inches, and was two inches thick outside the mouth. He used a special instrument, which clamped the tongue and allowed of ligatures being passed through holes in it; but he had to complete the arrest of haemorrhage by means of the cautery. Buttner, of Konigsberg, removed a " fleshy growth " from the tongue of a woman, aged twenty-seven, which had been growing since she was three years of age. The part projecting outside the mouth was three inches long, three broad, and two thick. Maurent gives two plates of patients with prolapsed tongue, macroglossia, and displacement of the jaw. A surgeon tried removal in one case, but was stopped by haemorrhage, for the arrest of which he recommends ice. Bieshaar used two semicircular incisions for the removal of a tumour the size of a nut from the middle of the tongue of a young girl. She had been attacked by frequent swellings, especially along with menstruation. After severe inflammation there was a good recovery. He preserved the tumour in spirits of wine, and thought it cancerous, but said that many would doubt this. C. C. von Siebold operated, in 1791, on a case of macro- glossia by strangulating it with ligatures. A weakly girl, aged ten, whose mother had been frightened during EIGHTEENTH CENTURY. a=>3 pregnancy by seeing a dead cow, had the tongue protruding four and a half inches from the teeth, being three inches broad and two-thirds of an inch thick. After making incisions around, a compressing ligature was applied, which gradually cut through, and the black slough was removed on the twenty-fourth day. Pyaemia occurred on the twenty- seventh day, followed by death. The skull of this patient is reproduced on p. 271. Virchow examined the preparation preserved in the \Yiirzburg Museum, and found that the macroglossia was the result of lymphangiectasis, and not of simple muscular hypertrophy. Louis wrote the chief memoir on the tongue during this century. He described one operation, the snipping off of a tumour the size of a small nut from the middle of a young man's tongue, afterwards applying caustic. Bertrand removed a large polypus from the base of the tongue by using a double ligature. Turner, in his "Art of Surgery" (1732), mentions that he opened a ranula in a girl, and removed a calculus ; also he sutured the tongue in a girl who had nearly bitten off the tip in an epileptic fit. Dr. Walter Harris, in his lecture given in the Royal College of Physicians of London on October 7th, 1720, says : " The excision of cancers of the mouth and lips, and especi- ally of the tongue, all involve the greatest danger to life. But if anyone is exceedingly wearied with such tumours, and especially dejected in mind, whilst he is prepared to bear equably whatever may happen, he should not be denied the trial of the operation of excision." He goes on to relate how a kindly neighbour of his who had neglected palliative treatment, on the advice of importunate friends, called in a famous surgeon, who at once persuaded the patient to have the cancer of the tongue excised. It turned out that this operator had lost both his previous cases. " A few days afterwards this case also went to the majority, and joined the two preceding ones in misfortune, whence no one ever returns to overcome the inalpraxis of ignorant physicians and of rash surgeons." Benjamin Bell, in his " Surgery," 1786, has a chapter on ulcers of the mouth and tongue and extirpation of the x 354 DISEASES OF THE TOXGUE. tongue. He cut round the growth, transfixed behind it with a row of gold pins or crooked needles, passed over these a wire loop, threaded through a double canula, and twisted up. This is an early instance of the ecraseur. He said that the actual cautery is the last resource, and concludes, as regards extirpation : " It ought not to be attempted by every operator ; for as it is always attended by a very sudden discharge of blood, the application of means proper for the stoppage of this and the obviating the effects of fainting and other unexpected difficulties which sometimes occur, require that steady deliberate coolness which a natural firm- ness of nerves, conjoined with much experience, alone can give." (d) Nineteenth Century. At the beginning of this century two English surgeons record operations on simple tumours, but apparently no case was cancerous. Home, in 1803, described cases treated by ligaturing en masse, one a nsevus in a boy, another a tumour the size of a pea in a woman, and a third of the same size in a man, removed after consultation with Cline. The sloughs included by the ligatures came away from the fifth to the ninth day, and this was followed by healing. Inglis, in 1805, operated upon a vascular lymphangioma in a man, aged twenty- four, which had been first noticed at the age of five, being then of the size of a small pea. It was surrounded by ligatures. On one of the ligatures becoming loose on the fourth day, another was applied. From the tenth to the thirteenth day there was much haemorrhage. In the fifth week the tumour separated, in the sixth week another application of ligatures was required to finish the removal, and healing was completed ten weeks after the first operation. The second case was a vascular angioma with lymphangiectasis near the tip of the tongue in a girl, aged ten; it was surrounded by ligatures. The sloughs came away on the ninth day, and healing was complete in five weeks. This painful and dangerous method of strangulation continued to be employed. It was applied to cases of cancer where it had not even the one redeeming method of ulti- mately curing. Illustrations occur in the text-books ; for MXETEENTH CENTURY. 355 instance, in Liston's " Practical Surgery," fourth edition, 1844, p. 293, it is the only method shown ; also as late as " Erich- sen's Surgery," eighth edition, 1884, vol. ii., p. 641. A more fearfully painful method still was the use of caustics. The tongue was drawn out, stabs made round the growth, and into the punctures arrowhead-like pieces of chloride of zinc were inserted. Girouard of Chartres, in 1857 obtained healing after thirty-eight days with a good result in a case of " cancer." Maissoneuve recommended the method in 1858. (e) The Beginnings of Present-day Operation*. - C. J. M. Langenbeck, in 1819, commenced the advance in the surgery of the tongue by introducing the wedge-shaped operation, applying, as he says, the V-shaped operation already in use for epithelioma of the lower lip, and so he obtained immediate union by suture, as Ambrose Pare had done for injuries. He applied no ligatures, and the sutures were removed on the third day. Major, in 1827, split the tongue down the centre and applied strangulating ligatures to the diseased half through the mouth. Cloquet, in 1827, commenced the methods of attacking the tongue from below the jaw, but it was in order to apply strangu- lating ligatures in a late case of cancer and ended fatally : the case is reported by Velpeau. A man, aged fifty-one, had had several syphilitic attacks, following which a fungating ulcer appeared on the tongue, and the glands became enlarged. Cloquet passed the strangulating ligature through a small incision below the jaw round the base of the tongue, using a curved needle on a handle, so as to strangulate the diseased part of the tongue. The patient died four days later of broncho-pneumonia, the glands breaking down and suppu- rating. The ligatures included all the diseased part of the tongue. Arnott.in 1839, used Cloquet's method of passing strangu- lating ligatures from below the jaw, and was successful, but his case was clearly one of macroglossia or, rather, lym- phangioma of the left half of the tongue, in a girl aged fifteen. The diseased portion sloughed away and healing followed. 356 DISEASES OF THE TONGI'I-:. G. Mimult, in 1833, first ligatured the lingual artery in the neck as a preliminary to removing a tumour of the tongue. A good deal of controversy seems to have arisen as to the originality and method of carrying out the operation. In the first place J. F. Mirault, the father, had removed, in 1813, a fungating and varicose tongue, which projected eight inches beyond the lips. The patient, a man aged thirty-four, had had a large tongue all his life. Three ligatures were used, and later on a wedge-shaped piece taken out of the lower lip. In the second place Velpeau and Blandin had described the method of ligaturing the lingual artery on the dead body, but had not apparently applied it to the living subject. Thirdly, Cloquet's method had already been published. The case which G. Mirault (the son) operated upon was apparently not cancer. A girl, aged twenty-three, in whose case syphilis could be excluded, had a fungating tumour with much swelling of the tongue, noticed for five months, and it had been much irritated by leeching and other treatment. Perhaps it was, as in other cases, a lymphangioma. On May 17th he attempted to ligature the left lingual artery, but failed to find it. On the next day, with the girl sitting in a chair, he tied the right lingual artery, following which there was some sloughing of the fungating tumour and the formation of a hollow ulcer. On June 6th secondary haemorrhage occurred from this ulcer, and so he proceeded to put strangulating ligatures on the left side, passed from the submaxillary region, after Cloquet's method. On June 16th he applied the strangulating ligatures also on the right side i.e. the side upon which he said he had done the preliminary ligature. Healing followed twenty-seven days after. G. Mirault certainly made the attempt to apply a pre- liminary ligature to the lingual artery in the neck. How far the idea was his own, and how far he carried it out, we have attempted to describe. Ja?ger, in 1831, was the first to divide the cheek (Fig. 35) in order to obtain more room for cutting away the tongue. A man, aged fifty-one, had cancer of the left half of the tongue as far as the base, which had extended to the left tonsil and floor of the mouth. He divided the cheek from the angle of REGXOLPS OPERATIO.\. 357 the mouth, drew the tongue out, cut round the ulcer and then cut away with strong harelip scissors. The cancerous part on the tonsil and floor of the mouth was removed with Cooper's scissors. The ranine artery was tied, and several small vessels twisted. Sharp fever followed, but the wound of the cheek and tongue had healed on the ninth day. Regnoli of Pisa, on May 18th, 1838, performed the removal of the tongue through the floor of the mouth by the .submental incision. It was done on a girl, aged fourteen, who had not menstruated, and was seen with a tumour the size of a hen's egg extending from the anterior third of the tongue backwards to the base, which so occupied the fauces that the posterior limit could not be made out until the tinger was inserted. The tumour occupied the whole thickness of the tongue, leaving a little of the right border free. The surface of the tumour was granular, it bled, especially during mastication and on examination with the linger, blood spurting out as from arteries. The mass was hard, nodular, painless ; mastication, swallowing, speech, and breathing were hindered, especially the latter. The tumour had certainly existed two years, but the patient's intellect was dull and her speech difficult to understand. The disease was certainly not epithelioma, but there is no account of an examination of the tumour after removal to assist one in recognising its nature. She was seated in a chair or stool opposite the window, with the head leant back against the breast of an assistant standing behind her. Regnoli then made, with a curved bistoury, an incision in the skin of the neck, from the middle of the symphysis of the jaw to the middle of the hyoid bone. (Fig. 33.) He then made two other inci- sions, one on the right, the other on the left, beginning at the chin end of the first and running outwards in the line of the base of the lower jaw as far as the anterior border of the inasseter, so that the facial artery was not wounded. These three incisions formed a T, and the two flaps, which included skin, cellular tissue, and the platysma myoides, wore dissected up, so that the muscular layer was exposed. A straight bistoury was now thrust from below upwards behind the symphysis of the jaw, so as to divide the 358 DISEASES OF THE TONGUE. insertions of the geniohyoid and geniohyoglossal muscles and the mucous membrane, until its point appeared in the mouth behind the incisor teeth. Through the same incision a blunt-pointed bistoury was passed from below upwards, and turned first to the right, then to the left, so as to divide the anterior insertions of the digastrics, the mylohyoids, and the mucous membrane of the mouth as far as the anterior Fig. 33. EEGNOLI'S STJBMEXTAL INCISION. pillars of the palate ; three or four vessels were tied. The tip of the tongue was seized with a pair of forceps and drawn down through the opening so that the whole tongue lay in the front of the neck. Regnoli seized it with his fingers, drew it as far down as possible, and surrounded the base by transfixing ligatures in order to guard against bleeding from the main arteries of the tongue. After he had com- pletely encircled the tongue and the disease with ligatures, he cut off with small scissors all the parts beyond the ligatures, which were left long hanging out of the wound. The cutting was very cautiously performed in order to guard against haemorrhage, and the surface of the stump was touched with the hot iron in order to arrest the oozing. EOUX AND SEDILLOT. 359 The stump was then returned into the mouth. Not a drop of blood had passed into the larynx. The external wound was not completely closed, in order to allow free drainage from the mouth, but was partly brought together with strapping and bandage. The patient made a good recovery, and healing was completed in six weeks. The stump hyper- trophied, and the patient spoke and swallowed well and was in better health than before the operation. lioux, in 1839, is the first to describe a major operation for the removal of a carcinomatous tumour such as might be carried out at the present time. A man, aged thirty-five, had had the disease for five months, and it occupied the entire left half of the tongue. It had commenced as an ulcer, and was attributed to smoking. The left lingual artery was first tied, then the tongue was freed from the floor of the mouth, from the lower jaw and from the anterior pillar of the fauces. It was then split by plunging into it a bistoury from its under surface, and the entire left half of the tongue cut away without haemorrhage. The patient spoke immediately after- wards without difficulty. On the tenth day the ligature came away from the artery, and the patient afterwards left the hospital well, a fine scar having formed in the mouth. Comparing this account with that of Mirault's, it is evident that Roux's case first demonstrated the value of the pre- liminary ligature of the lingual artery. Sedillot, in 1844, divided the lower lip in the middle line and then the lower jaw at the symphysis by an angular cut so that it should dovetail in when brought together again. Roux is said to have already done this operation, except that he divided the lower jaw vertically (Diet, de Med. et dc Cliir. Prnt, T. xx., 1875, p. 80) ; but we cannot make out where the original account is to be found. Sedillot, after separating the rami of the lower jaw, divided the left half of the tongue from the soft parts of the mouth, split the tongue down the middle, and cut away the left half immediately in front of the epiglottis. The lingual artery was tied without difficulty. The patient was a woman in good health; the jaw was fixed by a gold plate and by silk threads between the teeth. By the ninth day the lip had healed, and the case was practically well. 360 DISEASES OF THE TONGUE. Keith, in 1848, removed a large fungous tumour, which occupied the middle two-thirds of the right side of the tongue, from a woman, aged sixty-six. A warty excrescence had formed on the tongue four years before, commencing just behind the anterior pillar of the fauces, and had become a ragged ulcer, extending forwards nearly to the tip. With the patient seated in a chair and the head held, an assist- ant compressed the right carotid, and the tumour was cut off at one sweep with the knife. There was for the moment free hasmorrhage, for the patient moved and the carotid slipped away from the assistant's fingers ; but the dorsal and sublingual arteries were tied, and healing took place in a month. Unfortunately, the patient caught a chill going home, of which she died. Guthrie, in 1856, followed this method. In a man, aged seventy, he cut off the tip of the tongue and a part of the left side, and afterwards tied four bleeding vessels and stopped the capillary oozing with the cautery. Syme, in 1857, and again in 1858, repeated Sedillot's operation. Both cases were unsuccessful, but Fiddes followed with a successful case. After dividing and separating the two halves of the jaw, he had the tongue firmly stretched upwards and forwards by an assistant, who grasped it with a volsella. Then with scissors he cut away the tongue from the floor of the mouth with short cuts until he reached the lingual arteries on either side. As soon as these vessels were tied the tongue was cut away from the hyoid bone. (/) Ecraseur Methods. At this time removal by ecraseurs was introduced, and although excisions of the tongue came to be performed more frequently, the methods were not of permanent advantage and have been superseded. Surgeons were drawn to use them by the dread of primary haemorrhage and the rapidity with which the operation could be carried out. But all ecraseurs proved objection- able, partly OAving to the complicated apparatus, partly to the bruising, followed by septic infection and secondary haemorrhage, and also from the difficulty of preventing the noose as it was tightened from slipping forwards and en- croaching upon the tumour. ECEASEUR METHODS. 361 As mentioned on p. 354, Benjamin Bell used a double <'iinul;i, through which the wire for the ligature en masse could be threaded, and afterwards twisted up. Pins, or curved needles, thrust through behind the growth prevented the loop from slipping forwards. In 1852 Chassaignac first used his chain ecraseur at the Hopital St. Antoine. He did not tighten the chain so as to cut completely through until the end of forty-eight hours. In subsequent opera- tions the time for cutting through was twelve to twenty minutes. The ecraseur was a powerful apparatus which crushed through the tongue, leaving the stump bruised and lacerated. Curved needles were thrust through to keep the loops from slipping forwards. One. two, or even three ecraseurs could be applied e.g. one to cut across the tongue, one to divide it down the middle, and one to divide it from the floor. In order to pass the chain an armed needle was thrust through, withdrawn empty, and the liga- ture then used to draw the chain through. This was done through the mouth, and also from below the chin, by making punctures in the skin of the middle line. The operation was also combined with Sedillot's division of the jaw. Nunneley of Leeds, from 1861 to 1870, obtained remarkably good success as far as the immediate results were concerned. Thus, when he contested Symes' dictum that the excision of the tongue was an unjustifiable opera- tion, he had operated on five patients, who had all recovered. The galvano-ecraseur was also introduced about the same time. It was written about in the Lancet in 1851 by Hard- ing and Waite, and by Marshall in the " Medic o-chirurgical Transactions." Middledorpft', in 1854, wrote a monograph on "Die Galvano-caustik." The difficulties in its use were the troublesome apparatus and the uncertainty as to the heating of the wire. The current might at any time cease and leave the surgeon with a cold wire ecraseur, or get too hot and char the tissues, cut through the vessels and leave them bleeding, or fuse outright. Hence the use of the galvano-cautery was attended with dangers from primary and secondary haemor- rhage. An improved apparatus is in common use for small polypoid growths of the surface of the tongue ; it has mostly fallen into disuse for larger operations. Bottini, however, in 362 DISEASES OF THE TONGUE. 1894 published a hundred cases in which the galvano- cautery had been used, and Ostuani, in 1897, reports that Bottini continued to use it. The best immediate results with the ecraseur appear to have been reached by Morrant Baker. He used whipcord for the noose and tightened up slowly, taking fifteen or thirty minutes to cut through, at the end of which a tough strand was left containing the lingual artery, so drawn out that a ligature could be applied on the face of the stump, and the strand cut across between the ligature and the whipcord noose. But Baker also much improved the method of applying the noose, by adopting the preliminaries of Whitehead's operation: the mouth widely opened by a gag, the tongue well drawn out and freed from the attachment to the genial tubercles, the floor of the mouth and the anterior pillar of the fauces. In his later operations Baker mostly divided the cheek so as to get more room for working the ecraseur. Then two or more strong curved needles were thrust through the base of the tongue well behind the growth, which prevented the noose, passed below them, from slipping forwards towards the disease, when tightened. The recoveries which followed were most satisfactory, more than forty with only four deaths. Yet his latest com- munications show that he regarded the operation as essentially a palliative one. Thus, in 1884, after recording three cases of removal by the whipcord ecraseur, in which the cheek had been divided in all three and the jaw in one of the cases, also the glands were enlarged in all three, yet no special dissection was made to remove them, Baker remarked as follows : " In all the cases there might be a fair expectation that the ulcerating tumour would never reach the same dimensions as originally, and that not improbably recurrence might not happen to any extent in the mouth, but in the lymphatics, which were out of reach at the time of the operation." (g) There were other operations which excited a momentary interest, but in which conclusions had been hastily arrived at, and no development of surgery can be traced from them. Dieffenbach, in 1841, revived the old superstition that USELESS OPERA TIONS. 363 stuttering was connected with undue fixation or largeness of the tongue. Following the early publication of his case, in which he reported an improvement a merely temporary and superficial one Just says that more than two hundred cases were operated upon in England and France. The frsenum or supposed bands were divided, or wedge-shaped pieces cut out and the wounds united by suture. Finally, a case of Diefien- bach's died of recurrent haemorrhage. The operation was, of course, wholly irrational. Another group of operations were those connected with ligature of the lingual arteries. The cutting off of the blood supply to some tumours, generally of an unknown character, had been noted to be followed by their disappearance. Hence it was thought that real cancerous tumours might be cured in this way. Demarquay, in 1866, described a characteristic case under the title " Atrophy of a voluminous Tumour of the Tongue, obtained by Ligature of the two Lingual Arteries." A man, aged forty-eight, had an enormous tumour which hindered respiration, deglutition, and phonation. Both linguals were ligatured, the tumour completely disappeared, and the man entirely recovered. But no evidence is added as to the duration of this tumour, nor is. anything said as to its special clinical characters. It is impossible to do more than con- jecture that the tumour was inflammatory and recent in origin. The operation as applied to cancer might temporarily reduce congestion, and is applicable to occasional cases of irremovable disease where there is continuous hifinorrhage. It is certainly wrong to tie the linguals days or weeks before the tumour is removed, for the operation cannot arrest growth, but a free anastomosis is developed, so that when the surgeon comes to remove the tongue his anatomical know- ledge fails to guide him to the points where the blood is entering the tongue : there is more bleeding and more vessels to secure. It has been mentioned (Chapter XV.) that the bilateral ligature of the linguals may be of service in some cases of simple muscular macroglossia, but will not do more for the lymphangiomatous form than reduce congestion temporarily. Hilton, in 1850, first divided the lingual nerve opposite 364 DISEASES OF THE TONGUE. the molar teeth in order to relieve pain in inoperable cancer. Not very much good was done, and the results of subsequent attempts have been but indifferent. Instead of simply dividing the nerve, pieces have been cut out higher up, from the mouth or by trephining the ramus. But this does not touch the question of the glossopharyugeal nerve and the severe pain felt in the ear. Also, there are other means of relieving the pain than by submitting the patient to an operation, with the results of which he is sure to be dis- appointed. (Chapter XXII.) (h) The operations employed at the present time and described in the following chapter are divided into two groups. The excision of the tongue through the mouth, or buccal operation, is commonly known by the name of Whitehead's operation. This name is applicable because the procedures described by AVhitehead, in his papers from 1877 to 1892, are, as a matter of fact, very closely followed, barring excep- tional cases requiring special modifications. The genesis ot the peculiar features of the operation may be traced in earlier cases. Thus, Roux's operation in 1839 is the first clear demonstration of the plan of freeing the tongue from the floor of the mouth and drawing it well out; the value of this was emphasised by Sir James Paget, to whom Whitehead refers. Instead of amputating the tongue by one sweep of the knife, as did Keith and Guthrie, and later Fergusson, scissors were employed by Fiddes, making small snips until the blood-vessels were reached. By this operation the immediate mortality following ex- cision has become exceedingly small, and the operation has been generally employed. But attention has been more and more directed towards obtaining permanent results by dealing with the infected glands. (i) The second group of operations which provide for the removal, not only of the primary disease, but of its extensions beyond the tongue and of the widely infected lymphatic glands, with the object of obtaining a permanent cure in an increasing number of cases, are known collec- tively as the submaxillary, extra-buccal, or Kocher's operation. OPERATIONS TERMED " KOCHER'S. n 365 With regard to the use of Kocher's name, there is, in the first place, the operation as described by him in 1880, which had for its aim the thorough application of the Listerian methods to operations for the removal of the tongue; secondly, the Professor's description of his method in the most recent edition of his book on "Operative Surgery," in which are contained recommendations as to preliminary tracheotomy, division of the jaw, and the use of the cautery knife in removing the disease, in order to avoid septic infec- tion of the cut surface, from which many surgeons would differ; and thirdly, the general use of the term Kocher's operation for any and all the variations which surgeons have introduced into subinaxillary operations. Kocher's paper was a development of the experience gained by Billroth and his followers from 1861 onwards. The division of the cheek by Jaeger in 1831, the preliminary ligature (?) of the lingual artery by G. Mirault in 1833, at any rate by Roux in 1839, also the method of freeing the tongue by the latter, the division of the symphysis of the lower jaw by Sedillot in 1844, have been referred to. In 1859 B. von Langenbeck temporarily resected and turned aside the nose to remove a naso-pharyngeal polypus, and again in 1860 temporarily resected the upper jaw. These operations suggested to Billroth in 1861 the temporary resection of the lower jaw, between the right canine and the left molar teeth, for a recurrent cancer of the tongue. The patient recovered. At first there was some trouble in keeping the resected portion of the jaw in place, but after- wards union became firm. Billroth's second case required division of the jaw at the anterior borders of the masseters, with retraction of the proximal fragment. But the growth had extended deeply to the neck, an extensive removal was carried out, and the patient died on the third day from septic pneumonia. Boekel followed with another case of resection of the jaw, the fragments being united, but with some partial necrosis going on. The improvements and extensions made by Billroth and those who followed will be mentioned in the statistical results of operations. But a very notable advance was made by the introduc- tion of iodoform and gauze into use in Billroth's Clinic. 3(56 DISEASES OF THE TONGUE. Mikulicz, in 1882, describes the improvement following the use of iodoform and iodoform gauze. Wa'lfler, in his paper in 1881, does not mention the use of iodoform, but refers to a number of caustic materials, and gives the preference to permanganate of potash in powder. Iodoform was described from the pharmacological standpoint by Rhigini in 1861, and was employed for venereal and gynaecological purposes; also by Lister for foul ulcers of the leg. In the first twelve cases in which iodoform was used for the tongue healing followed, although most Avere very extensive removals. Von Langenbeck practised the removal of the back of the tongue when it had implicated the tonsillar region by lateral pharyngotomy and resection of the jaw. This form of operation is known in Germany as Yon Langenbeck's ; in English books it is often called Kocher's (see next chapter). CHAPTER XX. EXCISION OF THE TONGUE. The Buccal Operation : (a) Special Preparation of the Patient ; (/;) Apparatus ; (c) Assistance ; (d) Position of Patient ; (e) Anaesthesia, Tracheotomy, Laryngotomy ; (/) V-sliaped and other Local Excisions ; (g) Unilateral Excision, partial and complete ; (A) Bilateral Excision, partial or total ; (i) Examination and Dressing of the Stump ; (j) After-treatment The Submaxillary or Extrabuccal Operation "Kocher's Operation," Kocher's Antiseptic Method : () Excision of a Limited and Early Carcinoma of the Tongue, with all the Lymphatic Glands liable to be Infected in the Upper Part of the Neck, at two Operations ; (b) Cancer affecting the Floor of the Mouth and possibly the Lower Jaw (Laiigeiibeck's Operation) ; (e) Cancer of the Front of the Floor of the Mouth (Regnoli's Operation). L The Buccal, often called Whitehead's Operation. (a) Special Preparation of the Patient. It is almost hopeless to attempt to completely disinfect the month before operation, but the following measures are employed by some surgeons : During the few days intervening before the opera- tion attempts are made to diminish as much as possible the septic condition of the mouth. The patient, about every three hours, and after taking food, rinses out his mouth thoroughly with a mouth-wash permanganate of potash solution is the strongest antiseptic, having at the same time a non-irritating character. The patient cleanses his teeth as thoroughly as possible, using carbolised tooth-soap or carbolised tooth-powder. But more thorough measures are desirable whenever they can be carried out. The mouth is gently wiped out, especially the pockets, with soft pledgets of wool or bits of marine sponge soaked in bicyanide of mercury, 1 in 1,000, but the perchloride may be used, if preferred. Over the vascular granulations the solution is gently painted with a camel's-hair brush ; but if the growth is covered by hard, nodular epithelium, it will not hurt to rub it with a soft sponge, and try to clear all the fur and 368 DISEASES OF THE TONGCE. debris out of the sulci. In doing so no free fluid should esape into the mouth, and when the application is finished the patient well rinses out the mouth with water. The application may be made twice, or more often, in the day, the permanganate being used freely in the intervals; this may help diminish the septic decomposition in the mouth, and reduce the swelling and pain and salivation which this decomposition keeps up over and above that actually due to the growth. If possible, the teeth, and especially the carious ones, are actively treated with the same object. The healthy teeth are scaled, the partly carious teeth which can yet be preserved have their cavities cleaned out and a temporary filling inserted, those that are carious, also all stumps or others which may possibly irritate the future scar, are extracted and the sockets wiped out with an antiseptic. The patient's feeding should be considered, as regards strengthening him somewhat for the operation, especially if he has been nearly starved beforehand from pain in mastication and difficulty in swallowing. He should then rest in bed, have nutrient enemata, or be given liquid or soft food according to his power of swallowing. The relief granted by the disinfection in the mouth may allow him to take food much better than he had done for weeks before. Of course, if the patient is still strong and active, he should keep up his usual habits arid outdoor exercise until the operation. Besides this, the manner of giving food after the operation may be practised. A piece of rubber tubing is placed on the spout of a feeder, and the patient lets a little water into his pharynx at a time by pinching the tube between his thumb and finger, and relaxing for a moment to let that amount of fluid flow which he can then swallow ; or an oesophagus tube may be passed, after painting or spraying the back of the pharynx with cocaine ; an ordinary black olive-headed urethral catheter is generally the most useful. In this way the food may be taken better after the operation : indeed, by placing fluid food in the pharynx, or feeding by an resophageal tube, it will be more easy to improve the foul state of the mouth. The use of the above methods will vary with different patients, APPARATUS NECESSARY. 369 some of whom are, at least outwardly, stolid ; others are the better pleased the more is done for them ; and others, if too much fuss is made, get frightened and decline the operation. An exhausted patient may have a nutrient enema, with or without brandy, just before the operation. (6) Special Preparation of Apparatus; Table. The table required is most suitable when it corresponds to the height of the surgeon so as to bring the mouth of the patient, Fig. 34. MOUTH OPENED BY GAG, CHEEK RHTBACTED, AND TONGUE DRAWN Our. when partly raised, on a suitable level for the manipulations. A modern dental chair is also of service. Lirjht. Daylight from a window in front of arnd above the level of the patient is best of all, for shadows are avoided. Failing this, a bell-shaped electric hand-lamp may be directed by an assistant towards the mouth, or a forehead mirror and reflected light used when the day is dark. Gag. The object of a gag is to keep the mouth widely open. One not liable to shift, to retract, without pinching the cheek, which does not obstruct the light or the surgeon's manipulations, or damage the teeth or gums of the patient, is necessary. There are many forms and modifications used by surgeons and anaesthetists. The outline of a generally used form is shown in Fig. 34. It is called by instrument makers in this country Coleman's, or Mason's, or Fergusson's gag. It is now generally made entirely of metal, so that Y 370 DISEASES OF THE TONGUE. it can be sterilised. We have had a very large gag made in this shape for edentulous patients and for those who are restless under anaesthetics. Cheek Retractor. A cheek retractor is used, similar to the one shown in Fig. 34. Sponges. Small marine sponges, " button sponges," or pieces cut from a close-textured sponge, about one inch in diameter, are best. Marine sponges bring out ropy mucus better than anything else ; they are specially prepared and rendered aseptic, and should be burnt after use. Sponge Forceps. Six sponge forceps, closing to hold the sponge firmly, yet easily unlocked, are required. Curved Needles on Handles. Two are prepared, having, points like the larger-sized Hagedorn's needles, by threading them each with a stout silk ligature a foot long. Scissors. Two pairs of blunt-topped scissors are used for cutting, one pair straight, the other with the blades curved a little on the flat. They should be stout enough not to yield at their points when cutting through the tongue, yet without being clumsy. Knives. A straight-bladed finger knife and an ordinary scalpel. They may be required for dividing the surface of the dorsum along the middle line, for making a V-shaped incision, for outlining the growth, possibly for making a tracheotomy incision. Clamp Forceps. Six pairs of ordinary clamp forceps are required, one or two may have the jaw bent at an obtuse angle. It is contemplated in this operation that the disease can be brought out of the mouth at least up to the line of the incisor teeth, and if not, the case is seldom suitable for operating through the mouth only. Hence, there is no use for larger sorts of clamp forceps, nor should there be an occasion for putting them on within the mouth, where they obstruct the light, the surgeon's manipulations, the patient's breathing, and are difficult to tie over. Ligatures. We sometimes use catgut ; but for the last two or three years have generally used silk prepared by boiling ; No. 1 for the larger vessels, No. 00 for the fine vessels. Whilst the above are essential, the following should be at hand : POSITION OF PATIENT. 371 Volsella and Tongue Forceps. It is much better, and injures the healthy part of the tongue much less, to draw out the tongue by silk ligatures. But a volsella may be used to seize the growth, yet its points set up haemorrhage ; tongue forceps are apt to slip o"r to bruise the healthy part of the tongue. Tracheotomy tube with tapes, trachea dilator, a pair of small double hooks, a blunt hook, and a sharp hook. The tube is the double obtuse-angled one called Parker's, Trendelenburg's sponge cannula being unnecessary as the pharynx is guarded below by a sponge. The above instruments, being previously clean, may be laid in carbolic acid, 5 per cent, for ten minutes, then swilled with boiled water, and placed on a clean towel, or they may be sterilised instead of being put into the carbolic tray. Instead of being used dry, they may be laid on a tray in water, or in boracic or soda lotion. (c) Assistance. The surgeon requires the aid of an anaes- thetist, and at least one, preferably two, colleagues, also of one nurse. If there is only one assistant besides the anaesthetist, the latter may take charge of the head and the gag, and help with the sponging. If there are two, the second one can do this, leaving the anaesthetist free for emergencies. The first assistant holds out the healthy half of the tongue, or retracts the cheek on his side, whilst with the other hand he is ready to put a sponge on a bleeding point, or' to wipe out mucus and blood. (d) Position of the Patient. We attach great importance to this matter. Formerly, we were in the habit of placing the patient in the position advocated by Whitehead in a semi-sitting position, with the head held by an assistant in such a manner that it is about on a level with the axilla of the surgeon. But during the last two years, owing to the advantage which we found in the lateral position in' operating on patients with adenoid vegetations, we have been employing that position in almost every case of removal of the tongue. The patient is placed on his side, with the head a little forward and downward, so that the blood runs naturally into the cheek and out of the mouth. The surgeon may sit in front of the patient. We are very much impressed 372 DISEASES OF THE TONG !'!:. with the advantage of the lateral position in the more severe cases, where it is necessary to remove the tongue very far back, or to take out a thick piece of the floor of the mouth, or to deal with the tonsillar region in addition to the tongue. (e) Ancestltesia. A general anaesthetic is always used. Of course, small papillomata., etc., may be removed under cocaine, with the patient in a chair, as in minor nose and throat operations. But for all cases where anything serious is in question, a general anesthetic is required, The anaesthetic used is chloroform, but in most cases it is well to commence with nitrous oxide gas followed by ether. The patient is got under quickly, the mouth is well opened, the gag put into position, and the ligatures passed through the tongue. Then chloroform is blown in by the nostril or corner of the mouth through a soft metal tube connected with Junker's apparatus.* The Operation. The mouth is widely opened (Fig. 34) by the gag, and the tongue is drawn out by means of the stout threads passed through the forepart on either side. * A preliminary tracheotomy would render many of these operations much more easy to perform, but the objections to it have, to my mind, more than counterbalanced its advantages. The operation itself is often associated with a good deal of haemorrhage : the wound may do badly, and give more trouble than the wound in the mouth ; the patient finds it difficult to clear the upper air-passage of discharges. I have, therefore, seldom performed tracheotomy as a preliminary to the removal of the tongue, even when the operation in the mouth was likely to be severe. At a meeting of the Laryngological Society of London at the end of 1899, during a discussion on the treatment of a very large naso-pharyngeal growth, Dr. James W. Bond suggested a preliminary laryugotomy, and said that he had practised it in several similar cases ; for the operation itself was quite trivial and performed in two or three minutes. A sponge could be pressed into the lower part of the pharynx, so that the operation could be performed without the least fear of blood entering the air-passages; while the wound healed in two or three days. I was very much struck with the force of this suggestion, and determined to apply it in all large operations at the back of the throat, or, indeed, in the interior of the mouth, in which there is a likelihood of free haemorrhage. I have since done so in two cases of removal of half the tongue, in one case of very large removal of the upper jaw and surrounding parts, and in one case of extensive operation for naso-pharyngeal cancer. The results have, thus far. quite reached my expectation, and I intend to give the operation a very extended trial. H. T. B. PARTIAL OR UNILATERAL EXCISION. 373 (/) V-shaped Incision. For small tumours and ulcers, and especially when situated on the anterior third of the tongue, also for removing the superfluous portion of the tongue in macroglossia, a V-shaped incision is made either with scissors or a knife in such a manner that, after removal, the edges may be sutured together : in such cases no vessels may require to be tied. When the edges are drawn together haemorrhage ceases, or bleeding points are tied, then interrupted sutures of horsehair are inserted by cleft - palate needles and tightened. It is especially important to treat a tuberculous nodule in this way, so as to obtain primary union and avoid reinfection by bacilli in the sputa. (g) Unilateral Excision, Partial or Complete. The surgeon draws on one ligature and his assistant the other, and the tongue being thus held straight the surgeon makes an incision with the finger - knife through the mucous membrane of the dorsum, exactly in the middle line from a point well behind the level of the disease forwards to the tip. The mucous membrane beneath the tip is divided in a similar manner. Then with a finger of either hand the tongue can be split back along its raphe so as to avoid wounding the linguals of either side. A cut is made through the mucous membrane in the floor of the mouth, generally close to the jaw, and the cut is carried back behind the disease, generally by splitting the mucous membrane with the finger. Then the surgeon draws the diseased half forwards and upwards, making the geniohyoglossus muscle tense, and cuts through the muscle with scissors close to the genial tubercle. This may bring the surgeon to the anterior pillar of the fauces, which must also be cut through when the entire half has to be cut away. The affected half of the tongue should now have been so freed from its connections with the floor of the mouth that it can be drawn well out into view beyond the line of the teeth, and this should have taken place without any blood- vessel of importance having been injured. The affected halt is now removed rapidly by making short cuts with the scissors through the muscles attached to its base. The 374 DISEASES OF THE TONGUE. operation is, of course, performed from below upwards. The main vessel can usually be clamped before it is cut through. It lies near the middle line, and appears like a bluish- white cord in the midst of the muscles. The tongue can then be cut away quickly, the dorsal artery requiring to be clamped at the outer and upper angle. (Figs. 5 and 6, pp. 17, 18.) (h) Bilateral Excision. The tongue is drawn out of the mouth and upwards by the two stout ligatures, as in excision of one-half. The mucous membrane of the floor of the mouth is dealt with in the same manner, but on both sides. The anterior half-arches are divided if the disease extends far back. The tongue is raised up, so that the muscles attached to the base are made tense, and they are rapidly cut across with scissors until the entire tongue is separated on the plane of the inferior border of the lower jaw, as far back as the epiglottis ; or, if the disease is not very far back, to a point three-quarters of an inch behind the apparent margin of the cancer. The arteries are distinguished before they are divided, and are seized with clamp-forceps, so that the bleeding is reduced to a minimum. Just before the tongue is separated a ligature is passed through the tissues of the stump through the glosso-epiglottidean fold, if the entire tongue is removed as a means of drawing forward the floor of the mouth if there should be haemorrhage. This ligature may generally with safety be removed on the day following the operation. Until then it not only serves in cases of hemorrhage, but also to prevent the stump from falling back on the larynx. The operation, as described, is the operation of White- head, and we prefer it to any other for the removal of the tongue within the mouth. Instead of removing the tongue in one piece, however, we generally split it, especially if it is of very large size. It is usually easier to remove it in two halves, and the haemorrhage from the splitting is trivial. Mr. Whitehead was, and, we imagine, still is, in the habit of twisting the arteries. We prefer to place a ligature around them. If, by a mistake, the vessels are not clamped before they are cut, the blood spurts out with considerable force CONTROL OF HEMORRHAGE. 375 as the division is made. But the stream is out of the mouth, and the bleeding vessel can be secured in a moment. The vessels should always be permanently secured by twisting or tying before the tongue is completely separated. Indeed, the sooner they are dealt with after they have been clamped the better. The clamps are apt to become loosened and fall off, or to tear away from the soft tissues, if pressure be made on them, or if the patient should struggle. And it must be borne in mind that during large operations on the tongue it is by no means uncommon for a patient to come partly out of the anesthesia from time to time. If by any accident the tongue should be separated, either in whole or part, before the stump is controlled by ligature, or before the vessels are secured a very awkward accident, and one which ought not to take place Mr. Christopher Heath's recommendation must be borne in mind. The stump is drawn forcibly forwards by the fore- finger hooked around it, and the bleeding is thus temporarily arrested. When the blood has been sponged out of the mouth the vessels can be taken up and tied. (i) The Dressing of the Stump. After drying the surface of the wound, Whitehead swabs it over with a varnish made by substituting for the spirit ordinarily used in the pre- paration of Friar's balsam a saturated solution of iodoform, made by dissolving it in ether mixed with one volume in ten of turpentine. We more commonly employ powdered iodoform, or pack the surface of the wound with strips of the softest iodoform gauze, which, like the iodoform varnish, has the effect of rapidly stilling the oozing of blood. When the entire tongue has been removed, or half the tongue and a large part of the floor of the mouth on the same side, the wound is left open, and the foregoing methods are adopted. But when the disease is situated quite on the border or on the dorsum of the tongue, and does not penetrate deeply into the muscular substance, the operation may be modified in such a manner as to leave the mucous membrane of the floor of the mouth, and even that on the under surface of the front and side of the tongue. The incision through the membrane is made as far as is deemed 376 DISEASES OF THE TOXGUE. expedient from the jaw, and the mucous membrane and subrnucous tissues are separated from the parts beneath, which are cut across in the manner which has been described. The edges of the mucous membrane of the tongue and floor of the rnouth may be united with sutures after the tongue has been removed, and the upper surface may be joined by sutures to the lower surface of the tip and fore- part of the wound, so that little or no open wound remains. We are not very favourable to any attempt to close the wound completely, but frequently close part of it, especially the forepart, by attaching the mucous membrane of the dorsurn to that of the under surface. The patient is much relieved by even the partial closure of the wound, and swallowing is generally effected with less pain and difficulty. In closure of the back part of the wound, there is always the fear that a cavity will remain beneath the joined mucous membrane, and that blood may collect there and decompose, or that haemorrhage may take place into the cavity. We therefore seldom deal with this part of the wound. In case of troublesome oozing, however, where there is no vessel which can be tied with advantage, the oozing surface of the wound may be covered with gauze, and the gauze may be fixed in place by means of one or more silk sutures. This forms an effective hindrance to further loss of blood. The gag is now removed, and if there is a ligature through the stump, it is fixed loosely upon the cheek by a strip of strapping. (j) The patient is put to bed, lying on one side, with the head low, so that all the mucus escapes by the angle of the mouth on to a piece of wool and gauze or folded rough towel. If the patient lies in this position, there is little difficulty in keeping the mouth free from the collection of discharge, mucus, and saliva. If these materials cling to the interior of the mouth, and the patient is not able to get rid of them, the nurse gently wipes them out from the inside of the cheek with a small lump of sublimate wool on a pair of forceps, taking care to keep clear of the wound, and not to thrust the sponge into the pharynx. We generally . 1 1-'TER- TR EA TUB NT. 377 allow the patient to keep little pieces of ice in the mouth during the first day or two, and, if the pain is severe, as it often is, to have a quarter-grain morphia suppository. During the first twenty-four hours, food, if necessary, is administered by means of nutrient enemata. About three ounces of milk and beef-tea or strong beef-extract are given every four hours, with half-an-ounce of brandy, if stimulant is indicated, and, with that, ten minims of liquor opii, if the patient is very restless and suffers severely from pain. On the day following the operation, iodoform may be insufflated on the raw surface morning and evening, the mouth may be washed out with permanganate solution, and the gauze packing may be removed. But this is often left for forty-eight hours, or even for three days, when it comes away much more readily. As a rule, the patient can swallow on the second day, taking food from a feeder with a piece of india-rubber tubing on the spout. He lies on the sound side, and places the tubing on that side of the tongue, if only half of the tongue has been removed. In cases in which the operation has been very extensive, it may be necessary to feed through a tube and funnel. A soft catheter, one of the black bulbous or a vulcanised india-rubber, about No. 6 or 7 English, may be used for the purpose. It is fastened to a long piece of india-rubber tubing, to the other end of which is fixed a glass funnel. The catheter is smeared with oil or glycerine, and is introduced through the mouth or nose. A little water should be allowed to run down it first to be sure that there is no obstruction, and that none of the food is likely to make its way into the larynx and air- passages. The catheter need not be passed more than half- way down the resophagus. This feeding may be performed twice or three times in twenty-four hours, a pint or a pint and a half being administered on each occasion. The milk or beef-tea, or other liquid which is given, should not too quickly run into the stomach. The rate at which it runs can be easily regulated by raising or lowering the funnel, and the flow can be instantly stopped in case of need (itegoigitation or cough) by lowering the funnel to a lower level than the patient's mouth. After the nourishing 378 DISEASES OF THE TONGUE. liquid has been introduced, a little water is sent down into the stomach to clear the tube and catheter. The tube is raised and straightened in order to completely empty it ; it is then tightly pinched between the finger and thumb, and the catheter is withdrawn. By this means not a drop of liquid will find its way into the air-passages. Tube-feeding is generally preceded by a little cocaine sprayed on the back of the throat, and the patient is propped, up, or in the sitting posture. After the method has been established in the individual case, the catheter can be readily passed by a well-trained and intelligent nurse, so that, in case of need, the food can be administered by her at regular intervals. The patient will often himself regulate the rate of flow and assist in the removal of the catheter. It is scarcely necessary to suggest that the apparatus must be thoroughly cleansed after every time of use. 2. The Submaxillary, Extra-buccal, often called Kocher's Operation. All that has been described in the foregoing part of the chapter upon excision through the mouth applies to the more extensive operations now to be detailed. Hence there is no need to repeat what -has been already said, only to relate the additional measures connected with these operations. The various modifications are numerous, and there are several ways employed in reaching the same end. Recalling what was said at the end of the last chapter about the use of the name " Kocher," the special peculiarities of Professor Kocher's operation, as described in his original paper and in the last edition of his " Operative Surgery," we will now describe what may be called a typical operation for a favourable and early case viz. an excision of the lymphatic glands in the neck, whether these can be felt to be enlarged beforehand or not, along with the growth in the mouth, whilst preserving the floor of the mouth and other important structures. Then an account will be given of each of the chief further modifications required according to the position and extent of the primary growth or of the secondary glandular implications. The indications for the various operations are given later on. The operation described by Kocher in 1880 included a KOCHE'RS OPERATION. 379 preliminary tracheotomy and the ligature of the lingual artery on one or both sides, as well as the facial artery. Tracheotomy was performed and an ordinary cannula employed, Trendelenburg's cannula, which sometimes produces serious dyspnoea when it is inflated, not being necessary, on account of other precautions which were taken during and after the operation. The pharynx was completely filled by a sponge soaked in carbolic acid and attached to a string, by means of which it could be easily removed when necessary. The first incision (Fig. 35) was made along the anterior border of the sterno-mastoid muscle, commencing a little below the tip of the ear. From the first, a second incision was made from the middle of the sterno-mastoid muscle to the hyoid bone, and along the anterior border of the digastric to the jaw. The flap was turned up on the cheek, and the facial artery and vein and the lingual artery were tied. The sub- maxillary fossa was then completely cleared out, commencing from behind ; the lymphatic glands were removed, and even the submaxillary and sublingual salivary glands, if the dis- ease appeared to lie so near as to affect them. The mucous membrane was now divided along the lower jaw, and as much as was necessary of the mylo-hyoid muscle was separated from the bone. The tongue was drawn down through the opening, exposed with great ease, and re- moved either in part or whole with scissors or the galvano- cautery. The galvano- cautery was preferred by Kocher on account of the less liability of oozing after it had been employed. If the whole tongue was removed, the lingual artery of the side opposite to the operation was ligatured through a separate incision. Kocher laid great stress on the after-treatment, and on the treatment of the wound within the mouth. If the opera- tion was extensive, the external wound was not to be closed with sutures. The two great dangers of general sepsis and pneumonia from swallowing various matters were to be avoided by the following measures. The tracheotomy cannula was left in and allowed to lie loose in the trachea, as usual after tracheotomy. In order that the wound should not in the slightest measure be infiltrated by the discharges, the skin flaps were fixed back with sutures, and the entire 380 DISEASES OF THE TONGUE. cavity, from the entrance of the wound right back into the mouth and pharynx, was plugged with a tampon of sponge or gauze soaked in a solution of carbolic acid, 5 per cent. But before so strong a solution of carbolic acid was applied directly to the mucous membrane of the mouth, the tampon was just washed over with water. The sponge, or gauze, lay immediately on the epiglottis and root of the tongue, and filled the bottom of the wound as far as it is covered with mucous membrane. The naso-pharynx was treated in the same way as part of the general wound, only taking care to protect the mucous membrane from the acid as in the mouth. The whole operation was performed under the carbolic spray. The patient was fed partly by the rectum, but the feeding was accomplished chiefly when the dressings were changed. This was done twice a day; and before the fresh dressing was applied, nourishment was given through a tube introduced for the purpose into the stomach. The reason for particularly describing Professor Kocher's operation, is that it was the first, and perhaps the only, attempt which has been made to carry out the Listerian methods of antisepsis in operations for the removal of the tongue. This, which was the essential point in the opera- tion, has been generally overlooked, and the name of Kocher has been applied to the mere incision, the removal of the contents of the submaxillary triangle, and the taking out of the tongue, or of half of the tongue, through the opening in the neck. We do not know how far the antiseptic method is carried out at the present time, but the results which we have to show in this country lead us to believe that the following principles may safely be adopted in the treatment of the more or less complicated conditions which are met with in connection with cancer of the tongue. (a) Cancer of the Tongue, with or without actual Enlargement of the Lymphatic Glands. If the disease does not affect the floor of the mouth, and is limited to one-half of the tongue, or even if the floor of the mouth is affected, but not deeply, and it is decided to remove the glands, whether they are apparently diseased or not, we are quite sure the safest plan is to remove the tongue, or as much of it as may be necessary, first, and there is in such cases no REMOVAL BY TWO OPERATIONS. 381 reason to prefer the subrnaxillary to the buccal operation. If the disease of the tongue is very extensive, or the tongue is of very large size, the cheek may be incised in the manner ;uid to the extent shown in Fig. 35, But this is very rarely necessary when the operator is experienced in the removal of the tongue within the mouth. On the other hand, it may quite properly be adopted by young operators, and in cases in which the disease has extended from the tongue up into the tonsillar region, if the case is considered to be within the reach of operation. When the patient has completely recovered from the operation on the tongue, and can take food well which is generally in the course of three or four weeks the opera- tion for the removal of the glands may be undertaken with almost certain safety. For this purpose, we prefer the incision shown in Fig. 35, because it passes much farther down the neck than the incisions generally described. The skin is prepared in the manner usually employed at the present time, and the preparation should be made on the night previous to the operation, and be maintained until the moment of the operation. All the preparation of the patient is such as is usual before a considerable operation, and the instruments are such as are commonly employed for a large dissection. It must be borne in mind that about twenty clamp-forceps will be needed. The best ligatures and an abundant supply must be prepared are either of fine catgut or of very fine silk, No. 00, which should be boiled for a quarter of an hour or twenty minutes before it is used. The shoulders are raised on a pillow, the head is thrown back and the face turned well towards the sound side. Ether is generally administered at first, but as the operation occupies a long time, it is well to follow on with chloroform. The first incision (Fig. 35) is made along the anterior border of the sterno-mastoid muscle, and is six to eight inches long ; it passes down to the muscle, and the vessels are clamped on both sides as they are cut through. The second incision commences immediately below the symphysis of the jaw, and joins the first incision almost at a right angle, about the thyroid cartilage. These two incisions map out two 382 DISEASES OF THE TONGUE. triangular flaps: an anterior, with the apex looking backwards; a superior, with the apex looking downwards. The two flaps are turned back in such a manner as to expose the whole of the great anterior triangle of the neck. It must be borne in mind that the object of the operation is to remove (Fig. 7, p. 22) the submental, the submaxillary, the carotid, and the parotid Fig. 35. LINES FOR THE INCISIONS IN THE XECK, ALSO FOE THE DIVISION OF THE CHEEK. In the neck the dotted lines represent the incisions of the original operation by Kocher. The unbroken lines represent the incisions now used as described in the text (p. 381). The dotted line on the face represents where the cheek should be split. (superior carotid) lymphatic glands, and to do so with all the surrounding tissues, including the submaxillary salivary gland, perhaps also the sublingual gland, and often a part of the parotid salivary gland. The dissection is best begun at the apex of the triangle. The fascia and connective tissues are dissected off the muscles in front and the sterno-mastoid muscle behind, and off the sheath of the carotid artery and jugular vein. It is very important to thoroughly expose the carotid sheath, for over the bulbous dilatation at the division of the common carotid there is almost always a large gland, diseased, if the glands are actually affected. And below this gland there are often one or more smaller glands, of the same chain, which should be removed, and DISSECTION IN THE NECK. 383 which will only be removed if the dissection is carried down to the vessels at the ver} r apex of the triangle. The vessels which need division may, many of them, be clamped, tied in two places and divided without being previously cut. But it is not always possible to avoid wounding them, especially the veins, which are very thin-walled, and are apt to be mistaken for fascia. The operation should be performed deliberately. Nothing is gained by hurry, either in regard to the removal of the disease or to the prevention of haemorrhage ; indeed, with the greatest care, there will be a considerable loss of blood. The facial artery is taken up on the under and back aspect of the salivary gland, as this is raised up from its bed ; but it is necessary to tie it again as it passes on to the border of the maxilla, and with it the facial vein, which bleeds very freely. If the primary cancer is seated far back on the tongue, the submental glands will not be likely to be affected ; but if it is farther forward, they should be removed. They are often troublesome to find, but if the dissection clears away all the tissues between the skin and the muscles, and again between the muscles, they will be found in these tissues. Again, the parotid group of carotid glands is troublesome to deal with ; but by carrying the dissection up along the great vessels, and also behind them, the chain of glands will be cleared out. During the later stages of the dissection, when the submaxillary salivary gland and the parotid lymphatic glands are being removed, it is well to tampon the lower part of the wound which is now finished with ; and for this, purpose iodoform gauze is the best material. A great deal of unnecessary oozing of blood may thus be prevented. The operation occupies about an hour and a quarter, and the muscles of the anterior triangle, including those of the submaxillary triangle, are left quite bare. It is well to tie Wharton's duct, as a preventive to the possible infection of the wound from the mouth. This operation is usually rapidly recovered from; and this in spite of the fact that the Avound often becomes infected from the mouth, even when there is no obvious communication between the two. It is therefore proper to ensure drainage by means of a tube for the first three or four days, and later by a strip of gutta-percha tissue. The 384 DISEASES OF THE TONGUK. hollow left by the removal of the salivary gland is at tirst unsightly, because it throws the lower jaw-bone into relief as compared with the bone of the other side ; but this mends in the course of time. It must be remembered that this is a very severe operation, and when it is combined with a serious operation for the removal of a large part of the tongue, is likely to try the strength of the patient, even to death. For this reason it should be performed on a separate occasion. Two objections may be made to the division of the operation into two parts that the tissues between the primary disease and the lymphatic glands are not removed in one continuous mass with the primary disease and the glands, as they are in the modern operations for cancer of the breast ; and that the patient is subjected to the mental distress of a second severe operation on the recovery from the first operation. The first objection would be very serious if the anatomical relations between primary epithelioma of the tongue and the lymphatic glands were similar to those between spheroidal-celled carcinoma of the breast and the lymphatic glands in the axilla. But there are very good reasons for believing that they are not similar, and that the intervening lymphatic vessels are not infected or full of the cancer, and that it is therefore not necessary to remove them. The second objection must not be allowed to weigh against the thoroughness of the operation and the small danger to life when it is divided into two parts. This removal of the contents of the anterior triangle should be employed as a routine operation in all cases of squamous-celled carcinoma of the tongue, even when there is no obvious enlargement of the lymphatic glands. The difficulty is to decide what should be done in those cases in which the disease has crossed the middle line of the tongue, or is close upon it. Also, the comparatively rare cases in which the glands of both sides of the tongue are affected by a primary cancer which is quite limited to one border of the tongue. In all cases the best rule will probably be to remove the glands on the side corresponding with the side of the tongue on which the primary disease commenced. The patient should be under careful supervision for many VON LANGENBEGK'S OPERATION. 385 months afterwards, and the glands on the other side of the neck should be removed the moment any one of them is observed to be enlarged. Complete removal of the contents of the anterior triangle on both sides of the neck is a very severe procedure, and would gravely try the strength of any but the strongest patient. On the other hand, it would be very difficult to persuade a patient to undergo three operations, one or two of which would certainly appear unnecessary to hiiii. (6) Cancer of the Tongue affecting the Floor of the Month on the same Side, and involving a Portion of the Lower Jaw. Such cases, which are very unfavourable so far as cure is concerned, may be well dealt with by Yon Langenbeck's operation, which appears to be largely em- ployed on the Continent. A very free incision is made vertically along the side of the neck, up over the lower jaw, about the level of the last molar tooth, where the jaw is divided, and the two portions are turned back. The incision will, of course, depend on the part of the jaw which is involved, but the level of the last molar tooth is the usual situation of one of the incisions through it. The affected portion of the jaw is separated in front and behind by sawing. The sound portions of the jaw are turned outwards, and the soft parts are separated from them as far as may be necessary for the complete removal of the disease in the mouth. The glands which correspond with the disease are removed ; but as in most cases all the four groups of glands which were mentioned in the last operation are liable to be affected, the operation for their removal should be as large as that which has been described. For this purpose the original incision of Von Langenbeck needs to be supplemented. Such an operation as this is very dangerous to life. If it can be divided into two parts, consistently with the complete removal of the disease and of the contents of the anterior triangle, this is the wisest course to pursue. If this is not possible, the dissection should be commenced from below at the apex of the triangle, and all the vessels should be carefully and deliberately ligatured before the tongue is attacked, although the division of the jaw and the turning z 386 DISEASES OF THE TONGUE. back of the sound parts is desirable before the contents of the submaxillary triangle are removed. This part of the operation is thus rendered easier and more free from haemorrhage, especially if the external carotid artery is ligatured. Under these circumstances the removal of the affected portion of the tongue is singularly easy and bloodless. (c) Cancer of the Floor of the Mouth in Front, with more or less Implication of the Muscular tie ed., 1898, T.v. CHAPTER I. THE ANATOMY OP THE TONGUE. COMPARATIVE ANATOMY. Hunter, vide Specimens and Catalogue of the Physiological Series, Royal College of Surgeons' Museum, including plate xxx., with his description of the chameleon's tongue. Blandin, " Arch. Gen. de Med.," 1823, i., 459. Flower, Med. Times and Gazette, 1872, i. and ii. Gegenbaur, /'Morphol. Jahrbuch.," 1883-4, ix., 428; 1885-6, xi., 566; 1894, xxi., 1. Kathariner, "Jena Ztschrft. f. Naturwschft.," 1895, xxiii., 247, Taf. iii. Nussbaum and Markowski, "Anat. Anzeiger," Jena, 1896, xii., 551 ; 1897> xiii., 345. 444 DISEASES OF THE TONGUE. THYREOGLOSSAL TRACT. Boehdalek, "(Esterr. Ztschft. f. Prakt. Heilk.," 1866, xii., 683 et seq. His, "Anatomic Menschlicher Embryonen ; " ib., "Arch. f. Anat. v. Physiol. Anat. Abth.," 1891, 26. Streckeissen, " Ai-ch. f. Path. Anat.," 1886, ciii., 131, 215. Neumann, " Fortschritte der Med.," 1897, xv., 366. INCISIVE GLAND, llerkel, " Handbuch der Topographischen Anatomic," Bd. i., S. 287. LINGUAL TONSIL. Swain, "Deutsch. Archiv f . Klin. Med.," 1886, xxxix., 504. Stohr, " Festschrft. Niigeli u. v. Kolliker," 1891, 19. LINGUAL ARTERY ANOMALIES. Dubrueil, "Des Anomalies Arteriells," Paris, 1847. Zuckerkandl, " Wien. Med. Wchnschrft.," 1881, 833 (with drawing). Shepherd, Annals of Surgery, 1889, ix., 331 (with drawing). Croly, Trans. S. Acad. Ireland, 1890-1, ix., 275. Funke, "Archiv f. Klin. Chir.," 1897, liv., 322. Gruber, "Archiv f. Path. Anat.," 1878, Ixxiv., 427. LYMPHATICS AND LYMPHATIC GLANDS. Sappey, "Descript. et Iconogr. des Yaisseaux Lymphatiques," Paris, 1885, p. 71, pi. xxi. Soffiantini, " Atti d. xi. Cong. Med. Internaz. Eoma," 1894, ii., "Anat.," 69. Kiittner, "Beitr. z. Klin. Chir.," 1898, xxi., 732 (with plates). Keisse, " Anat. Hefte," Merkel u. Bonnet, Heft. 32, 1898, a. 287. Rawitz, "Anat. Anzeiger," 1898, xiv., 463. NERVES. Superior Laryngeal Nerve. Laborde, " Les Tractions Ehythmees de la Langue," Paris, 1894. Lepine, Lancet, 1886, i., 520 (two other cases by Viaud in 1894). CHAPTER II. THE CONGENITAL DEFECTS OP THE TONGUE. ABSENCE AND ARRESTED DEVELOPMENT. Jussieu, "Hist, de 1'Acad. des Sciences," 171S. Aurran, " Elinguis Feminae Loquela," 4to., Argent, 1766. Kolliker, " Entwicklungsgeschichte," 2te Aufl, 1876. Duplong, " Bull, et Mem. de la Soc. de Chir.," Paris, 1883, n. s., T.ix., 457, with cases by Lucas Champoniere and by Trelat. Ahlfeld, " Missbildungen des Menschen," 1882. Septours, "Union Med.," Paris, 1876, 3 me ser., xxi., 209. Griffiths, Brit. Med. Journ., 1899, ii., 273. AUTHORITIES. 445 Bifid or Cleft Tongue. r, " Arch. f. Klin. Chir," 1890, xl., 79-). Brothers, Mi. Bw., X. Y., 1888, xxxiii., 109. Barling, lint. M,d. Journ., 1885, ii., 1061. CONGENITAL ANKYLOGLO8SIA, OR TONGUE-TIE. Popper, "(Esterr. Med. Wchnsehrft. Wion.," 1842, 988. Joachim, " Jahrh. f. Kinderheilk," 1889, n. F. xxix., 236. Hemorrhage after Dirition of the Frtenum. Burton, Lancet, 1897, i., 241. Reboul, " Lyon Med.," 1897. Ixxxvi., 86. Division of Frtenuni and Macroglossia, vide Macroglossia. Division of Frceiium and Singing. Tassius, Lancet, 1889, ii., 444. Division of Franum and Stuttering. Dieffenbach,: " Die Heilung des Stotterns dureh eine neue Chir. Operation," Berlin, 1841. Makuen, Intermit. Clinic, Phila., 1897, 7 ., i., 319. EXCESSIVE MOBILITY. Tongue Sicalloicing. Petit, "Mem. Acad. Roy. des Sciences," 1742, 247. Sinking Both of Tongue. Fairbairn, Med. Times, 1845, xii.. 392. Ingals, Arch, of LaryngoL, ii., 134. In Whooping Cough. Hennig, " Jahrb. d. Kinderheilk," n. F., 1877, xi., 299. Depression of Tongue causing Respiratory Spasm. Vergel, Brit. Med. Journ., 1890, i., 1508. Tongue Sucking. Lindner, " Jahr. f. Kinderh.," 1879, xiv., 68. CHAPTER III. ACCIDENTS TO THE TONGUE AND ACQUIRED DEFORMITIES. BURN*. Eichhorst, " Handb. d. Spec. Pathol. u. Therap.," Bd. ii. ; case recorded by Spry. WOUNDS. Bites of the Tongue. Legg, Wickham, " Treatise on Hemophilia," 1872. Hobbs, Med. Press and Circ., 1887, n. B., xliv., 78. .Makuna, Brit. Med. Jottrn., 1890, ii., 630. 44o DISEASES OF THE TONGUE. Lacerated Woititt/. Norgdte, Med. Times and Gaz., 1857, xiv., 283. Perforation and Fixation by a Tooth. Nsegeli, " Correspondenzblatt f. Schweiz Aertzte," 1894, S. 40. Bullet Wounds. Baker, Brit. Med. Journ., 1883, i., 457. Range, "Arch, de Med. Nav.," Paris, 1887, xlviii., 310. Punctured Wounds, Fatal. Cooper, B., Guy's Hosp. Rep., 1838, ii., 404. Hamilton, Lancet, 1837, ii., 816. FOREIGN BODIES (see also " Actinomycosis "). Legouest, " Traite de Chir. d'Armee," 2 me ed., 1872. Seiler, Archives of Laryngology, vol. i., 276. Gibb, Lancet, 1866, i., 710. Weber, "Ztschr. d. deutsch Chirverein," Magdeb., 1852, v., 351. Anderson, Austral. M. Gaz., Sydney, 1896, xv., 399. Fork, Lancet, 1846, i., 73. Potter, Med. Rec., N.Y., 1866, i., 179. ACQUIRED ANKYLOGLOSSIA. Belebat, Roland de, " Aglossostomographie," Saumur, 1630. (Copy in R.C.S. Library.) Boddington, ''An Account of Margaret Cutting," Phi!. Trans., 1732-44, ix., 126. South, in his trans, of Chelius' "Surgery," Lond., 1847, vol. ii., 315. Vausarit, Med. News, Phila., 1894, ii., 606. Routier, " Bull, et Mem. Soc.de Chir. de Paris," 1889, n. s., xv., 707. Powell, Brit. Med. Journ., 1898, ii., 1875. Tearing out the Tongue. The earliest illustration is an Assyrian one. Layard, " The Monuments of Nineveh/' Lond., 1853, 2nd Ser., pi. 47. The original is in the British Museum. ACQUIRED EXCESSIVE MOBILITY. Jurist, Med. Rec., N.Y., 1885, xxviii., 539. Winslow, ,, 1886, xxix., 66. Wherry, brit. Med. Journ., 1887, i., 335. Bourdette, " Ann. de Mai. de 1'Oreille, du Larynx," etc., 1897, xxiii., 474. CHAPTER IV. SEMEIOLOGY ; DISCOLORATIONS. SEMEIOLOGY. Dickinson, ' Lumleian Lectures," Lond., 1888. Bactericidal Action of Saliva. Hugenschmidt, "Ann. 1'Institut Pasteur," 1896, x., 545. AUTHORITIES. 447 Fur on the Tongue. l.utlin, Proc. Roy. Soc., March, 1879. Butlin, ,>V. Bart's HO.IJ). Rep., 1879, xv., p. 37. Hutchinson, Med. Pi-fs* mil ('in:, 1883, ii., p. 2. Micro-organisms in the Mouth. WashbDurn and Goadby, Brit. Jo urn. of Dental Sc., 1895, xxxix., 673. Goadby, Brit. Journ. of Dental Sc., 1898, xli., 769. Raw Tongue Henry, Austral. Med. Journ., 1887, n. 8., ix., 217. Kirk, Lancet, 1899, i., 581 (in " Myxcedema "). XEROSTOMIA. Hall, A. J., Quart. Med. Journ., Sheffield, 1898-9, viii., 26. Harris, Am. Journ. Med. Sc., Phila., 1898, n. a., cxv., 312. PSILOSIS, OK SPKUE. Thin, Brit. Med. Journ., 1890, i., 1357, with plate. DISCO LOR ATIOXS. Xdtithelnsma. Legg, Wickham, St. Bart?* Hasp. Sep., 1874, x., 244. Addlson's Disease. Fowler, Train. Clln. Soc., 1885, xviii., 323, with plate. Pigmentation In Exhausting Disease. Greenhow, Trans. Path. Soc., 1873, xxiv., 94. Danlos, "Ann. de Dermat. et Syph.," 1897, T. viii., 1284. Blood Stains. Froriep. "De Lingua Anatomica," 1828. Tinctorial Dlxcolorations and Stains with Caustics. Kial, " Diet, de Med. et Chir. Prat.," 1875, art. " Langue.'' Dickinson, Trans. Path. Soc., 1885, xxxvi., 476. Schimmer, "Ann. de Dermat. et Syph.," 1896, T. vii., 399. VARICOSITY OF RANINE VEIN'S AND CEREBRAL CONGESTION. Dickson, Brit. Med. Journ., 1885, i., 888, 1152. \Vhitehouse, 940. Atkinson 1040. Greenwood ,, 1095. Gillot, "Union Med.," Paris, 1888, 3 s. xlv., 801. CHAPTER V. ACUTE PARENCHYMATOUS GLOSSITIS ; ACUTE ABSCESS ; GANGRENE. ACUTE GLOSSITIS. Mackenzie, S., Practitioner, 1881, vol. ii., p. 271. 448 DISEASES OF THE TONGUE. Micro-organisms in the Month and on the Tongue. Washbourn and Goadby, Brit. Journ. of Dent. So., 1896, xxxix., 673. Goadby, Brit. Join-it, of Dent. Sc., 1898, xli., 769. Bactericidal Action of Sali>'". Hugenschmidt, "Ann. de 1'Institut Pasteur," 1896, x., 545. L/tdwia's Angina. Von Ludwig. " Med. Correspondenzblatt d. Wurtemburg. Aertz. Landverein, vi., 1836. Casselberry, " Journ. Laryngol. Rhinol v. Otol.," 1898, June. Streptococcal Glossitis. Garel, "Ann. de Mai. de POreille, du Larynx/' etc., Paris, 1891, xvii., 305. Sabrazes and Bousquet, " Ann. de Dermat. ct Syph.," 1897, viii., 513. Spencer, Lancet, 1899, i., 161. ACUTE ABSCESS. Colby, St. Bart. J s Hosp. Rep., 1889, xxv., 257. Acute Hamorrhagic Glossitis. Myguid, Journ. of Laryngol., Lond., 1890, iv.. 1. Mercurial Glossitis. Stromeyer, " Cbir. Krankh. d. Kopfes," 1868, 152. Brown, Lancet, 1832-3, ii., 9. GANGRENE. Sloughing of Tongue. Banon, Dublin Quart. Journ. Med. Sc., 1864, xxxviii., 448. Pritchard, Brit. Med. Journ., 1862, ii., 487. Mendel, "Ann. de Dermat. et Syph.," 1894. v., 1364. Eustace, Brit. Med. Journ., 1893, i., 845. Von Gietl, "Deutsch Klinik," 1852, iv., 70, 79. Moriarty, Ind. Med. Gaz., Calcutta, 187o, x., 325. Phagedena. Vincent and Coyon, "Ann. de 1'Institut Pasteur," 1896, T. x., pp. 489, 661. Noma. Lingard. Lancet, 1888, ii., 159. Bishop and Ryan, Journ. Am. Med. Ass., Chicago, 1895, xxv., 1043. Schmidt, " Jahrbuch f. Kinderheilk," 1898, xlviii., 172. Anthrax. Heyfelder, " Med. Vereinszeitung," 1834. Rammstedt (Von Bramann's Klinik), Brit. Med. Journ., 1899, ii., epit. 6. CHAPTEE VI. ACUTE SUPERFICIAL GLOSSITIS. PARENCHYMATOUS HEMIGLOSSITIS. Duckworth, Sir D., Liverpool Med. Chir. Journal, 1883, July, p. 195. De Mussy, "Arch. Gen. de Mod.," 1879, 3 rae ser., viii., p. 385. Graves, " Clin. Med.," 2nd ed., vol. ii., p. 196. AUTHORITIES. 449 NERVOUS OR HERPETIC HEMIGLOSSITIS. (untrrbock, "Deutsch. Ztschrft. f. Chir.," 1885-6, xxiii., 487; 1886-7, xxv., 486. Mackenzie, S., Practitioner, 1881, xxvii., 266. MEMBRANOUS GLOSSITIS AND DIPHTHERIA. VVharton, Med. Xeics, Phila., 1895, Ixvi., 406. Hall, De Havilland, Jirit. Meil. Jourti., 1898, ii., 153. Hutchinson, in his Archives of Surgery, 1895, vi., 368. THRUSH. Vogel, " Ziemssen's Handbuch," 1874-77, vol. vi., h. i., p. 60. West, "Diseases of Children," 7th ed., Lond., 1884. APHTHA EPIZOOTICS; FOOT-A.VD- MOUTH DISEASE. Siegel, "Deutsch. Med. AVochnschrft .," 1891, xvii., 1328; 1894, xx., 400, 426. Bussenius and Siegel, ib., 1897, xxiii., 65, 91. Siegel, "Areh. f. Laryngol. v. Rhinol," 1895, iii., 172. Stembo, "St. Petersb. Med. Wochnschrft.," 1896, n. F., xiii., 204. CHAPTER VII. SUB-ACUTE AND CHRONIC SUPERFICIAL GLOSSITIS. ERYTHEMA MIGRANS, OR WANDERING HASH. Bridon, " Une Affection Innomee de la Muqueuse linguale," Inaug. Diss., 1872. Caspary, " Viertljhrschft. f. Derm. u. Syph." n. F., 1880, vii., 183. Unna, ib., 1881, viii., 295. Parrot, " Progres Med.," 18S1, p. 191. Fournier, in discussion following paper by : Bandouin, "Ann. de Dermat. et Syph.," Par., 1898, 3 s., ix., 554. Hutchinson, in his Archives of Surgery, 1892-3, iv., 156. Vanlair, " Rev. Mens de M&L et de Chir.," 1880, vol. iv., p. 153. THE RAW, EXCORIATED TONGUE. Hack, " Monat. f. pract. Dermat.," 1882, vol. i., p. 2; abst. in "Schmidt's Jahrbucher," 1883, pp. 128, 197. Dyspeptic Excoriations. Thomson, Lancet, 1890, i., 900. Goodale and Hewes, Am. Journ. Med. S'., Phila., 1899, n. s., cxvii., 423. Dissecting Ghssitis. "Wunderlich (see Demarquay, " Xouv. Diet, de Med. et de Chir. Prat.," 1875, xx., p. 145, Fig. 11). Sulcated Tongue. Hutchinson, in his Arch, of Sitrg., 1895, v. 394 ; 1897, viii., 170. GLOSSODTNIA EXFOLIATIVA. Kaposi, " Wien. Med. Pressa," 1885, xxvi., 361 et seq. Degle, ib , 1886, xxvii., 1528. D D 450 DISEASES OF THE TONGUE. HERPES AND HYDROA. Von Michelson, " Berl. Klin. Wchnschrft.," 1890, xxvii., 1055. Hall, De H., Westminster Hasp. Rep., 1888, iv., 167. Rosenthal, " Deutsch. Med. Wchnschrft.," 1894, xx., .549. Willan, "Cutaneous Diseases," vol. i., p. 527, 1808. Fournier, "Gaz d'H6p," Paris, 1892, Ixv., 913; "Rev. Internat. de Med. et de Chir.," 1897, viii., 309. Hutchinson, in his Arch, of Surg., 1898, ix., p. 114. CHAPTER VIII. CHRONIC SUPERFICIAL GLOSSITIS. LEUKOKERATOSIS, LEUKOPLAKIA, OR LEUCOMA. Lawrence, Lancet, 1862, i., 459; 1863, i., 93. Neligan, Dublin Quart. Journ. of Med. Sci., 1862, Aug. Hulke, Trans. Clin. Soc., 1869, ii , 1. Debore, " Le Psoriasis buccal," Paris, 1873. Schwimmer " Vierteljrschft. f. Derm. u. Syph.," 1877, p. oil. Hutchinson, Med. Press and Circ., 1883, vol. ii. Pathology of Chronic Superficial Glossitis. Butlin, Tram. Med. Chir. Soc., 1878, Ixi., 51. Sangster, Trans. Path. Soc., 1882, xxxiii., 103. Leloir. " C. R., Acad. de Sci.," Paris, 1887, civ., 1747. Nedopil, " Archiv f. Klin. Chir.," 1877, xx., 324. Excision of Leucomatous Patches. Ransohoff, Annals of Surgery, 1899, May, p. 577. Leiikokeratosis and the Arthritic Diathesis. Barthelemy, " Ann. de Dermat. et Syph.," 1896, vii., 356. LEUKOKERATOSIS AND SKIN AFFECTIONS. Kcratosis of the Skin. Morrow, Med. News., Phila., 1886, xlix., 295. Church, St. Bart. Hosp. Rep., vol. i., p. 198. Colleville, "Gaz. hebd. de Med.," Paris, 1838, n. s., iii., 277. Brocq, see Jullien, " Ann. de Dermat. et Syph.," Paris, 1896, vii., 95. Crocker, " Atlas of Diseases of the Skin," vol. ii., pi. Ixxxviii., fig. 4 and 5. Lichen Planits. Hutchinson, "Lectures on Clin. Surg.," vol. i., pp. 213, 256; also in his Archives of Surgery, 1892-3, vol. iv., 315; 1893-94, vol. v., p. 19: 1897, vol. viii:, 58. Dubrueilh et Freche, " Ann. de Dermat. et Syph.," 1897, viii., 519. Hallopeau, " Ann. de Dermat. et Syph.," 1897, viii., 198. Simple Psoriasis. Lacoarret, "Rev. hebd de Laryngol.," Par. 1898, xviii., 817. Schiitz, "Arch. f. Dermat. u. Syph.," 1898, xlvi., 433. Lissauer, "DeutechMed. Wchnschrft.," 1899, xxv., 12. AUTHORITIES. 451 follow in y Lupus. Du Castel, " Ann. de Dermat. et Syph.," 1897, viii., 480. Followed by Tuberculous Uleeratinn. Tlioiuson, Brit. .!/> Paris, 1889, 2s., x., 849. Darier, 1895, 3 s., vi., 631. Stonham, Westminster Hosp. Rep., 1899; also, Hebb, Trans. Path. Soc., 1897. xlviii., 62. Excision. Bull, Med. Rec., N.Y., 1889, xxxv., 62. Pean, " Lecons de Clin. Chir.," 1892; T. viii., 631, 633. Shepherd, Annals of Surgery, 1888, vol. viii., 368. LEPROSY. Carter, V., " Leprosy," p. 55. Campana, Med. Rec., 1884, p. 214. ACTINOMYCOSIS. Illich, "Beitr. z. Klinik d. Aktinomykose " Wien, quoted by Mikulicz u. Kummel. Hummel, "Beitr. z. Klin. Chir.," 1895, xiii., 535. Maydl, Lancet, 1889, ii., 1151. Hebb, Trans. Path. Soc., 1899, L. 61. (L. Cooper's case.) ANIMAL PARASITES. Guinea Worm. Davaine, " Traite des Entozoaires," 1877, 2 me ed., p. 562. Hillier, Indian Med. Rec., Calcutta, 1892, iii., 79. Trichina. Miller, Trans. Path. Soc., 1849, ii., 138. See also " Internat. Centralblatt f. Laryngol.," 1894. CHAPTER XL SYPHILIS OF THE TONGUE. Hard Chancre. Fournier, Gaz Med. de Paris, 1894, i., 601. AUTHORITIES. 453 Fournier, " Les Chancres Extragenitaux," Paris, 1897. Bull, Lancet, 1888, ii., 241. (irillin, Med. Sec., N.Y., 1892, xlii., 393. Solibcr, Aim. Xn,-g. t Phila., 1895, xxii., 353. Williams, Trans, din. Soc., 1899, xxxii., 57. Soft Sore. Emery and Sabourand, "Ann. de Dermat. et Syph.," 1896, 3 8., viii., 198. Mucous Patches. Bumstcad and Taylor, "Venereal Diseases," 4th ed., 1879, p. 585. Butlin, Practitioner, 1883, vol. xxx., p. 175. Tertiary Syphilitic Plaques. Fournier, "Des Glossites Tertiaires," Paris, 1877. Syph ilitic A trophy. Lewin and Heller, " Arch. f. Path. Anat.," 1894, cxxxviii., 1 (with plates). Seifert, "Arch. f. Dermat. u. Syph.," 1898, Bd. xliv., 212. Tertiary Nodules and Dots. Penny, Bristol Med. Chit: Jonrn., 1888, vi., 37. Stewart, Lancet, 1888, i., 1293. Hutchinson, in his Arch, of Sttrg., 1893-4, v., 74. Gummata and Tertiary Ulcers. Heath, Brit. Med. Journ., 1888, i., 833. Hutchinson, in his Arch, of Siny., 1891-2, iii., 361. Butlin, St. Bartholomew's Hosp. Rep., 1889, xxiv., 83. Robertson, Lancet, 1893, i., 1514. CHAPTER XII. TUMOUBS AND CYSTS OF THE MUCOUS SALIVARY GLANDS J SALIVARY CALCULI. HYPERTROPHY. Congenital. Braquehaye and Sabrazes, " Eev. Mens. des Mai. de 1'Enf.," 1897, xv., 429. ABSENCE OF SUBMAXILLARY GLAND. Bruno, " Atti di XI. Cong. Med. Internaz., Roma, 1894," ii., Anat. 62. TUMOURS. Enchondroma. Butlin, Trans. Path. Soc., 1877, xxviii., 228. Endotheliutiui . Volkmann, R., " Deutsch Ztschrft. f. Chir.," 1895, xli., 61. Kuttner, "Beitr. z. Klin. Chir.," 1896, xvi.. 181. Lotheisen, "Beitr. z. Klin. Chir.," 1897, xix., 481. Lowenbach, "Arch. f. Path. Anat.," 1897, cl., 73. (Jriffin in Embryonal Rests. Jacobson, Guy's Hosp. Rep., 1883, xli., 205. Von Hinsberg, "Cent. f. Chir.," 1899, 983. 454 DISEASES OF THE TONGUE. Adenoch ondroma, Hutchinson, J., jun., Trans. Path. Soc., 189", xlviii., 63. Curtis, Trans. Path. Soc., 1898, xlix., 85. Lane, Trans. Clin. Soc., 1891, xxiv., 17. Adenollpoma. Waring. Trans. Path. Soc., 1899, 1., 67. Myxoma. Beadles, Trans. Path. Soc., 1897, xlviii., 66. Cystic Degeneration. Hayes, Med. News, Phila., 1893, Ixii., 600. Papilliferoits Cystadenoma. Planth, " Beitr. z. Klin. Chir.," 1897, xix., 335. Angiojibroma. Fischer, " Deutsch Ztschrft. f. Chir." 1889, xix., 581. Adenoma of Blandin's Gland. Morisani, "Boll. d. Clin. Milano," 1890, vii., i. RANULA. Congenital Origin. Lannelongue, " Bull. Soc. Anat.," 1879, v. 398. ^f;/.fomato us Degencra lion. Suzanne, "Arch, de Physiol. Norm, et Path.," 1887, 3 ser., x., 141, 375. Cirrhosis of Connective Tissue. Mintz, Cent. f. Chir.," 1999, 982. Subliitoual Ranula. Baker, M., St. Bartholomew's Hosp. Rep., 1871, vii., 134. Morestin, "Gaz. d'Hop.," 1897, Ixx., 529. Excision of Sublingual Ranula. Von Hippel, "Arch. f. Klin. Chir.," 1897, lv., 164, 893. Felizet, " Bull, et Mem. Soc. de Chir.," 1891, n. s., xvii., 603. Acute Ranula. Richet, "Union Med.," 1880, xxiv., 716. French, Med. Rec., N. Y., 1888, xxxiv., 507. Du Canes, Lancet, 1890, i., 463. Chronic Ranula, External or Lateral. Paget, Sir J., in his " Study of Old Case Books," 8vo., Lond., 1891, 152. Icisire Gland Raindn. Paget, S., Trans. Path. Soc., 1892, xliii., 57. Blaiidin's Gland Ranula. Von Recklinghausen, " Arch. f. Path. Anat.," 1881, Ixxxiv., 425. Sonnenburg, "Arch. f. Klin. Chir.," 1883, xix., 627. Fcederl, ib., 1895, xlix., 530. Curtis, Ann. of Snrg., 1898, xxvii., 662. AUTHORITIES. 455 SALIVARY CALCULI. In Child. Wright, "On the Physiology and the Pathology of the Saliva," Lond,, 1842 (child, art. 9). Srhrnck, " Observ. Med. Kara?," lib. vii., 166") (one child, set. 7; another, set. 12). Large. Puzey, Lancet, 188-1, i., 424. Power, Trans. Path. Soc., 1888, xxxix., 103. Chemical Composition. Lindemann, " Deutsch Med. Wchnschrft.," 1895, xxi., 683. Bacteria. Toison, "Cent. f. Chir.," 1899, 49. Origin in it Mucous Plug. Thornington, M,-d. XCH-X, Phila., 1892, Ixi., 188. Multiple. Spencer, Trans. Path. Soc., 1898, xlix., 85. In JHandin's Gland. Zacutus Lnsitanus, ride Gurlt, iii., 438. (A smooth, hard stone the size of a hazel-nut removed from the tip of a man's tongue.) In Blaitdiifs Gland, Sarcoma around. Godlee, Trans. Path. Soc.. 1887, xxxviii., 346. Diagnosis from Tumour. Hulke, Lancet, 1894, i., 9. Kappeler, "Deutsch Ztschrft. f. Chir.," 1882, xvi., 369. Kiittner, "Arch. f. Klin. Chir.," 1898, Ivii., 873. CHAPTER XIII. CYSTS OF THE TONGUE. EPIDERMAL OR DEBMOID CYSTS. Barker, Trans. Clin. Soc., 1883, xvi., 215 ; 1891, xxiv., 68. Morris, Med. Times and Gaz., 1884, i., 43. Paget, S., Trans. Path. Soc., 1886, xxxvii., 225. Button, " Dermoids," Lond., 1889. Green, Trans. Clin. Soc., 1889, xxii.. 28. Flinn, Trans. . Avad. Med., Ireland, 1890, viii., 222. Routier, " Bull, et Mem. Soc. de Chir.," 1893, n. s., xlx., 171. Klapp, " Boitr. z. Klin. Chir.," 1897, xix., 609. Furnivall, Trans. Path. Soc., 1898, xlix., 64. BLOOD CYSTS. Bryant, Guy's Ho*p. Rep., 1883, xli., 140. Clarke, W. B., Lancet, 1887, i., 881. PARASITIC. Cystieereus and Echinococcus, or Hyatid Cystx. Roser, "Arch. f. Heilk," 1861, ii., 370. ShillitOf, Tr,<*. Path. Soc., 1863, xiv., 170. 456 DISEASES OF THE TONGUE. Hofmokl, " Anz. k. k. Ges. Aertz. in Wien," 1877, Mai 11. Molliere, "Prog. Med.," 1875, p. 2. Andre, " Bull. Soc. Anat. de Paris," 1898, Ixxxiii., 264. Gosselin, "Gaz. d'Hop.," 1869, 213. Prechaud, " Arch. Clin. de Bordeaux." 1894, 508. CHRONIC ABSCESS. Mosse, " GHZ. Hebd. de Med.," 1898, n. a., iii., 1105. CHAPTER XIV. DISEASES OF THE BASE OF THE TONGUE; THYREOGLOSSAL CYSTS AND T I'M OURS. "THE LINGUAL TONSIL. Follicular Inflammation. Craigie, Edin. Med. and Surg. Journ., 1834, xlii., 19. Fleming, Dublin Quart. Journ., 1850, x., 87. Fraenkel, B., " fieri. Klin. Wchnschrf t. ," 1873, 94. Sievenham, " Arch, f . Laryngol. u. Rhinol," ii., 365. Kelly, Glasgow Med. Journ., 1896, xlvi., 81, 179, with plates. Friedland, " Ztschrft. f. Heilk.," 1896, xvii., 275. Follicular Abscess. Knight, Med. Bee., New York, 1890, xxxviii., 233. Wetmore, Montreal Med. Journ., 1892-3, xxi., 823. J I j/l)i'> trophy. Baron, Bristol Med. Cliir. Journ., 1890, viii., 80. Roe, Trans. Amer. Laryngol. Assoc., 1890, N. Y., 1891, xii., 125. Tumours. (See also Sarcoma, Ch. XVII.) Rosenberg, "DeutschMed. Wchnschrft.," 1892, 283, 311. Mycosis Fungoides. Hallopeau et Jeanselme, "Ann. de Dermat. et Syph.," 1892, 3s., iii., 1262 1893, iv., 277. VARICOSE VEINS AT THE BASE OF THE TONGUE. Richardson, Journ. Am. Med. Assoc., 1889, xii., 119. Kersting, " A r erhandl. d. Physik Med. Gessellschft. z. Wiirzbnrg," 1890, xxiii. Tilley and others, Lancet, 1896, i., 413, 512, 654. 735, 802, 859, 885. Bottome, Laryngoscope, 1898, Jan. Grant, Journ. of Laryngol., Rhinol., and Otol.. 1897, July. THYREOGLOSSAL CYSTS AND TUMOURS. At the Base of the Tongue. Hickman, Trans. Path. Soc., 1869, xx., 161. Bryant, Guy's Hosp. Rep., 1883, xii., 140. Streckeisen, " Arch. f. Path. Anat.-," 1886, ciii., 131, 215. Bernays, St. Louis Med. and Surg. Journ., 1888, iv., 201. Wolf, " Cent. f. Chir.," 1889, xviii., "Kong. Beil," 51. Butlin, Trans. Clin. Soc., 1890, xxiii., 118. A UTHORITIES. 457 Williams. /.nnc<-t, 1899, i., 251. Lang, lirit. Med. Joiirn., 1892, ii., Epit, 46. \Varn-n, Ti'nnx. .\mi-r. Sun/. Assn., 1892, x., '213. (ialisch, "Doiitsch Ztschrft. f. Chir.," 1894, xxxix., 560. Baber. Proc. Lari/ngoL Soc. of Land.. 1894, Oct. 10, p. 1. Mcllraith, lint. M>-d. Joitni., 1894, ii., 1234. Von Chamisso de Boncourt, " Beitr. z. Klin. Chir.," 1897, xix., 281. Lympius, "Deutsch Ztsehrft. f. Chir.," 1897, xliv., 451. Seldowitsch, JS'. Y. Med. Join-it., 1897, Ixv., 666. Bracquehaye et Sabrazes, " Rev. Mens. d. Mai. de 1'Enfance," 1897, Sept. \Vi, .singer, "Deutsch Ztsehrft. f. Chir.," 1897, xliv., 451. Reintjes, " luternat. Cent. f. Laryngol," etc., 1899, xv., 174. .lohnson, Lancet, 1899, i., 562. In the Th i/roli yoid Region. Chaslin, "Prog. Med.." Paris, 1886, 2 s., iii.. 227. Schlange, "Arch. f. Klin. Chir.," 1893, xlvi., 392. Reverdin et Buscarlet, " Rev. Med. de la Suisse Rom.," Geneve, 1893, xiii., 761. Liaras, "Mem. et Bull. Soc. de Med. et Chir. de Bordeaux," 1896, 54. Chiari, " Wien. Klin. Wchnschrft.," 1898, xi., 1133. Durham, H., Trans. Med. Chir. Soc., 1894, Ixxvii., 199. Waterhouse, C'fin. Joiirn.. Lond., 1897-8, xi., 246. Beek, Med. Bee., N. Y., 1894, xlv., 537. HYOID BONE. Dislocation. Wood, Lancet, 1890, ii., 232. Caries. Uhlmann, "Wien. Med. Presse," 1898, xxxix., 921. Sypkifii. Elliot, Jour it. Cutan. and Gen. Urin. Dis., N. Y., 1893, xi., 7. Tumours. Le Dentu, " Bull, et Mem. Soc. de Chir. de Paris," 1888, n. s., xiv., 499. Spisharny, "Deutsch Med. Wchnschrft.," 1892, xviii., 853. Anderodias et Hugon, " Gaz. Hebd. de Med. et de Chir.," 1893, June 3, p. 525. Boeckel, "Gazette de Strasbourg," 1862, quoted by Spisharny. CHAPTER XV. HYPERTROPHY OF THE TONGUE, OR MACROGLOSSIA. LYMPHAXGIOMATOUS MACROGLOSSIA AND LYMPHANGIOMA. Fissured Tongue, or Lingua plicdta. Bark, Liverpool Med. Chir. Jottm., 1890, vol. x., 517. Lymphangioina. Barker, Trans. Path. Soc., 1890, xli., 70, with plate. Hutchinson, J., jun., Trans. Path. Soc., 1890, xli., 79, with plate. Morton, Trim*. Path. Soc., 1893, xliv., 58. Ribbert, " Arch. f. Path. Anat.," 1898, cli., 381. 458 DISEASES OF THE TONGUE. Lymphangiomatoits Macrogloxsia. Humphry, Trans. Med. Chir. Soc., 1853, xxxvi., 113; Hodgson, ib., p. 129. Virchow, in his ' Arch.," 1854, vii., 126. Chalk, Trans. Path. Soc., 1857, viii., 305. Vernon, St. Bart's Hasp. Rep., 1865, i., 6'2. Maas, "Arch. f. Klin. Chir.," 1871, xiii., 413. Winiwarter, "Arch. f. Klin. Chir.," 1874, xvi., 600. Fayrer, " Clin. and Path. Observ. in India," 1878, p. 537. Maguire, Joitrn. Anat. and Phi/ s., 187$, xiv., 417. Francis, A. G., St. Bart's Hasp. Rep., 1893, xxix., 143, with Bibliography. Hutchinson, in his Arch, of Surg., 1895, vi., pi. Ixxxvi. Brault, "Ann. de Mai. de 1'Oreille, du Larynx.," etc., 1897, xxiii., 417; 1898. xxiv., 481. Tenneson, "Arch, de Dermat. et Syph.," 1898, ix., 984. Following Division of Franmiii. Sedillot, "Gaz. des Hop.," 1854, 102. Dollinger, "Arch. f. Klin. Chir.," 1878, xxii., 701. Following Treatment of Ranula. Leah, Brit. Med. Journ., 1893, i., 581, with photo. Following Operation on Lower Jaiv. Girerd, N"., " Journ. Med.," Paris, 1880, i., 17, 28. Deforming Lower Jaw. Von Siebold, "Chiron," 1805-6, i., 651. Glutton, personal communication. Deformity of Lip. Mirault, J. F. (pere), vide Mirault, G. (fils), " Mem. Acad. de Med. Par.," 1835, iv., 35. MUSCULAR MACROGLOSSIA. Galen, ed. Kiihn, vi., 869. Eickenbusch, " Beitr. z. Klin. Chir.," 1894, xi., 273. Kopal, "Prag. Med. Wchnschrft. ," 1895, xx., 341. With Idiocy and Cretinism. Parrot, "Bull. Soc. d'Anthrop. de Paris," 1881,3s. iv., 752; also "Gaz. des Hop.," 1881, 50. Bruck, "Deutsch Med. Wchnschrft.," 1889, xv., 229. Baginsky, "Paediat Arbeiten," Berlin, 1890, 514. Helbing, " Jahrb. f. Kinderheilk," 1896, xl., 442, with Bibliography. Fehleisen, "Berl. Klin. Wchnschrft.," 1887, xxiv., 941. Combined Muscular and Li/inphangiomatous. Zeisler, N. Y. Med. Rec., 1885, xli., 253. INFLAMMATORY HYPERTROPHY. Williamson, Lancet, 1881, i., 136. Fournier, " Des Glossites Tertiaires," Paris, 1877. CHAPTER XVI. INNOCEXT TUMOURS. CONGENITAL TUMOURS. Studenski, "Journ. d. Chir. u. Augenh.," 1834, xxt., 313. AUTHORITIES. 459 LI POM A. Listen, "Pi-act. Surg.," 1846, 4th ed., p. 292. I'.astien, "Hull, de la Soc. Anat.," Paris, 1854, 349. Churchill, 7V",,*. Path. Soc., 187:2, xxiii.. 235. Guelliot (Gosselin), ' Pr. ..irivs Mod.," 1880, viii., 1014. Malon, " Des Lipomes de la Langue," Th. de Paris, 1881. Monod, "Bull, et Mem. Soc. de Chir.," 1881, vii., 365. Kirchhoff. "Deutsch Med. Wchnschrft.,' 7 1889, xv., 457. Kydyirier, "Arch. f. Klin. Chir ," 1891, xlii., 768. Martcl, "Rev. de Chir.," 1896, xvi., 52. Foster, Lari/nyoscope, St. Louis, 1898, iv., 347. Multiple Lipoma. Chevasse, Lancet, 1896, ii., 1607. Barling, Brit. Med. Journ , 1885, ii., 1061. Cauchois, "Bull, et Mem. Soc. de Chir.," 1883, ix., .->7'J. Diffuse Lipoma. Bond, " Proc. Laryngol. Soc. of Lond." 1898-9, p. 8. FIBROMA. Bastien, " Bull. Soc. Anat.," 1854, 349. Richard, " Gaz. des Hop.,'' 1855, 453. Billroth, " Arch. f. Path. Anat.," 1856, ix., 303. Folker, Lancet, 1863, ii., 445, with plate. Max ,n, Trans. Path. Soc., 1864, xv., 210 ; 1867, xviii., 249. Alhert, "Wien. Med. Presse," 1885, xxvi., 168. Barling, Brit. Med. Journ., 1885, ii., 1061. Kirchhoff, "Deutsch Med. Wchnschrft.," 1889, xv., 457. FIBROMYOMA. Blanc, " Gaz. Hebd. de Med.," 1884, 2 s. xxi., 611. BHABDOMYOMA. IVndl, "Ztschrft. f. Heilk.," 1897, xviii., 457. FIBROCHOXDROMA. Berry, Trans. Path. Soc., 1890, xll, 81. Lang, Brit. Med. Journ., 1892, ii., epit. 46. AMYLOID TUMOURS. Ziegler, " Arch. f. Path. Anat.," 1875 ? Ixv., 273. Schmidt, "Arch. f. Path. Anat,," 1896, cliii., 369. AXGIOMA. Arteriovenous Anenry&m. Despres, "Bull, et Mem. Soc. de Chir.," 1879, n. s., v., 794. Gay, Lancet, 1874, ii., 269. Cirsoid Aneio'ysm. Bryant, Guy's Hosp. Rep., 1883, xli., 143. Fayrer, " Clin. Surg. in India," 1866, 485. Mott, -V. ]'. .!//. Frets, 1859, n. s., ii., 829. 460 DISEASES OF THE TONGUE. Neevi. Mendel, " Ann. de Dermat. et Syph.," 1894, v., 817. Reinbach, " Beitr. z. Klin. Chir.," 1897, xviii., 451. Acquired Capillary J\" r/iaye. Heath, vide Holmes, and Hulke, " System of Surgery," 3rd ed., 1883, ii. , 609. Suture of Mucous Membrane Flaps. Maunsell, New Zealand Med. Journ., Dunedin, 1890-1, iv., 29. Lane, A., .Lancet, 1892, i., 129. Berger, " Bull, et Mem. Soc. de Chir. de Paris," 1891, n. s., xvii., 86. Repair of Deformity after Removal of Middle of Lower Jaw. Boyd, S., Tram. din. Soc., 1894, xxvii., 287. Harris, Journ. Brit. Dent. Ass., 1896, xvii., 227. Transhijoidean Operation. Yallas, Lyon Med., 1898, Ixxxix., 81. Boyd and Bond, Tram. Clin. Soc., 1899, xxxii., 274. CHAPTER XXI. QUESTIONS CONNECTED WITH OPERATWNS. CASES KNOWN TO BE ALIVK, OR TO HAVE DIED WITHOUT RECURRENCE, TEN YEABS OR MORE AFTER OPERATION. Butlin, 13 years, see p. 397. Spencer, 12 years, see p. 117, Fig. 8. Buchanan, 30 years, Edin. Med. Journ., 1894-5, xl., 769. Hutchinson, 19 years ("many 8 to 10 years"), in his "Arch, of Surg.," 1898, ix., 289; also Clin. Joitrn., 1892-3, i., 271. Stonham, 13 years (case lately seen, W. G. S.), Clin. Soc. Trans., 1886, xix., 312. Whitehead, 14 years (two eases), Lancet, 1888, i., 169 ; 1891, i., 1032. Wheeler, 15 years, Dublin. Journ. Med. Sc., 1897, ciii., 281, 343. Heath, 23 years, Lancet, 1899, i., 1355 (operation Sept. 29th, 1875, nee Trans. Path. Soc., 1876 ; patient died of old age Jan., 1899); and 15 years (opera- tion Sept., 1869 ; patient died in 1884, aged 78, of senile decay). Kronlein, 12 years, vide Binder, " Beitr. z. Klin. Chir.," 1896, xvii., 253. CASES OF LATE RECURRENCE. Pean, al'ter 15 years, " LeQons de Clin. Chir.," 1892, viii., 637. Kocher, after 12 and after 10 years, vide Sachs' "Arch. f. Klin. Chir.," 1893, xlv., 774. Crerar, after 6 years, Brit. Med. Journ., 1885, ii., 755. OPERATIONS FOR RECURRENT CANCER (iii-aud, "Echo Med.," Toulouse, 1892, vi., 293. Hollres, Chicago Med. Rec., 1893, v., 31. .M;i kins, Trans. Clin. Soc., 1896, xxix., 193. Briddon, Med. and 8urg. Reporter, Presbyterian Hosp., N. Y., 1897, ii., 131 Symonds, Brit. Med. Journ., 1888, i., 1272. PALLIATIVE TREATMENT. Buccal Antisepsis. G-aston, "Aim. de Dermat. et Syph.," 1899, x., 155. E E 466 DISEASES OF THE TONGUE. CHAPTER XXII. NERVOUS AFFECTIONS OF THE TONGUE. NERVOUS SBMEIOLOGY. Hilton, " Rest and Pain," 3rd ed., 1880, 207. Pasquier et Marie, " Progres Med.," 1891, 2 s., xiii., 107, 123, 227. GLOSSALGIA. Glossodynia Exfoliativa. Kaposi, "Wien. Med. Presse," 1885, xxvi., 361 et seq. Degle, "Wien. Med. Presse," 1886, xxvii., 1528. Xerostomia. Haddon, Lancet, 1890, i., 183. Bernhardt, "Neurol. Centralblatt," 1890, ix., 389. Dygpeptie. Thomson, Lancet, 1890, i., 900. Rheumatic. Chomel, " Lemons de Clin. Med.," Paris, 1837, ii., 49, 178. Magitot, "Gaz. Hebd. de Med.," 1887, 2 s., xxiv., 788. Painful Papilla 1 ; Lingual Papillitis. Albert, " Real. Encyclop.," art. " Zungenkrankungen," 1883. Duplaix, "Gaz. des Hop.," 1893, Ixvi., 1157. Gazzola, "Ann. de Dermat. et Syph.," 1894, v., 1301. Reflex. Hill, Brit. Med. Journ., 1882, ii., 683. Stretching and Resection of Lingual Nerve. Hilton, Guy's Hosp. Rep., 1851, 2nd ser., vii., 253. Moore, Trans. Med. Chit:, 1862, xlv., 47. Roser, "Arch. f. Phys. Heilk.," 1855, xiv., 579. Vanzetti, "Gaz. des Hop.," 1868, 30. Lucas, Brit. Med. Journ., 1884, ii., 975. Dubrueil, " Semaine Med.," 1892, xii., 14. Bristow, Brooklyn Med. Journ , 1897, xi., 201. Walsham, " Surgery," 6th ed., Lond., 1897, p. 314. PARyESTHESIA ; IMAGINARY ULCERATION. Verneuil, Lancet, 1887, ii., 787 ; " Bull. Acad. de Med.," 1887, 2nd s., xviii., 4'_'4. VASOMOTOR DISTURBANCE ; ANGIONEUROTIC (EDEMA. Lewis, JV. Y. Med. Journ., 189", Ixvi., 494. Kirk, Lancet, 1899, i., 579. GLOSSOPLEGIA OR PARALYSIS. Trevelyan, " Brain," 1890, xiii., 102. Nuclear. Jackson, H., Lancet, 1872, ii., 770. Hirt, "Berl. Klin. Wchnschrft. ," 1885, xxii., 411 ; 1886, i., 689. Eskridge and Rogers, Med. News, N. Y., 1896, Ixix., 176. Mackenzie, S., Trans. Clin. Soc., 1886, xix., 317. AUTHORITIES. 467 Pcto, also Ross, v ide Koch et Marie, "Rev. do Med.," 1888, viii., 1. H.m.ik. ' JJ.Tl. Klin. \\Vhnschrft.," 1886, xxiii., 401. Raymond et Artaud, "Arch, de Neurol.," 1884, vii., 146. PARALYSIS OF THE HOOT OF THE HYPOGLO8SAL. SypkiKtic. Turner, Trans. Hunter. Soc., 1889-90, 84. .Tacoby, Boston Med. and Surg. Journ., 1893, cxxviii., 219. Lewin, " Berl. Char. Annal," 1882, viii., 602. Holthouse, vids Trevelyan. Traumatic. Paget, Sir J., Trans. Clln. Soc., 1869, iii., 238. Morrison, Brit. Mul. Jonni., 1888, ii., 7-'). Barlow, Trans. Clln. Soc., 1889, xxii., 322, pi. xiii. Hydatid l'i/*t. Choisy, " Bull, de la Soc. Anat.," 1832, 114 ; 1833, 6. Xeic Growth. Hughes Bennett, sec Trevelyan. PARALYSIS OF THE TRUNK OF THE HYPOOLOSSAL. Traumatic. Schiffer, " Rev. Mens. de Laryngol.," etc., Paris, 1886, vi., 37". Berahardt, "Archiv f. Klin. Med.," 1878, xxii., 392. Babinski, "Bull, et Mem. Soc. Mod. des Hop. de Paris," 1896, 3 s., xiii., 671. Moger, N. Y. Med. Jonni., 1897, Ixvi., 173. Hutchinson, Med. Times and Gaz., 1872, i., 431. Inflammatory. Birkett, Montreal Med. Joitrn., 1890-1, xix., 641. SPASM OR CRAMP. Dochmann, "St. Petersb. Med. Wchnschrft.," 1883, p. 4. Berger, "Neurol. Centrlblt.," 1882, i., 49. Remak, " Berl. Klin. Wchnschrft. ," 1883, xx., 513. Vallin, "Gaz. Hebd.," 1865, p. 262. Jolly, "Ziemssen's Handbuch," vol. xi., pt. 2, p. 488. Mitchell, Trans. Med. Chir. Soc., 1813, iv., 25. Ganghofner, " Centralblt. f. Med. Wissenschft.," 1883, 240. Lange, " Arch. f. Klin. Chir.," 1893, xlvi., 705. Gallebrani and Pancinotti, Brit. Med. Journ., 1893, ii., Epit. 45. INDEX. Abnormalities. iS H, 109 ; Acute, 73 ; Chronic, 240 ; Folli- cular. .'.',! i Absence (so-called). 27 Abulkusim or Albucasis. Surgery, 350 Aeqoapendente, Fabric! us, ab. Division of Fr;i-nuin, 31, 350 Acute Abscess, 73 ; Glossitis, Parenchyma- tous. i;r, ; Sniicrlicial. 7:' Addison's Disease, Black Marks, r.i' Adenoma (so-called), 2;>7 Adherent Tongue, 30 -Kgina. Paul of. Clamp for Hemorrhage, 350 After-treatment of Operations, 370 ; involving floor of Mouth, 389 ; involving Neck, 383 Ageusia, 419 Ahlteld. Bitidity. 29 Albert. Enlarged Papillae, 410 An inonia, Effect of, 40 Amyloid Tumours. Anatomy, Comparative and Surgical, 1 Ana'stlie.sia, 410 Aniesthetie for Operations, 372 Anderodiaset Hugou. H void Bone Tumour, MS Anderson. Foreign Body, 49 Andre. Hydatid Cyst. 2 to Aneurysm, Arteriovenous, Cirsoid, or by Anast!ii gig, 288 Angioina. 2>7 Angioneiirotic (Kdcnia, 419 Animal Parasites, 185 Ankyloglossia. Acquired, 50; Congenital, :!0 ; Sujierior, 32 Annulus Migrans, or Wandering Rash, 94 Anthrax. 77 Aphtha- or Thrush, 84 ; of Bednar, 85 ; Epizootic*, 91 Apoplexy and Varicose Ranine Veins. 04 Apparatus for Excision. 309 Arnold and Bastieii. Chondroma. 286 Arnott. Lymphangioma removed by Stran- gulation, 347 Arrest of Development, -J7 Arteries, External Maxillary or Facial, I'.i ; Lingual. 1". Arteriuveiinus Aneurysm, _'-< Artii'iilatory Crani]>. 4:l; Atkinson. Varicose Ranine Veins and Cerebral Congestion. !."> Atrophie Carcinoiiia. ::_'::. :;L". Atrophy, Muscular, 420; .Superh'eial in old 80; in Syphilis, 204 Aurlie et Carriere. Tuberculous Ulcers. 172 Audrey et Iversene. T'llierculoils Pspilloma, 174 Aurelianus, Ca-lius. Scarification for Man o- glossia, 340 E E* B. Babinski. Traumatic Glossoplegia, 4-.'7 Bacteria of Mouth, 71 Baker, Morrant. Bullet Wound, 4i ; Excision by Bcrueor, 302; Guiamatous L'leer liecoming Can-inoma, 310; Keloid, L".i7 ; Hanula, 232 Billiard. Hemiglossitis, 82 Banon. Gangrene, 71; Bare Tongue, v.> Barker. Macroglossia, 2tiS ; Wandering Rash, K Barling. LijMima, Multiple, 2S2 ; Sarcoma, 302 Barlow. Traumatic Glossoplegia, 4'_'"> Base of Tongue, Affections of, 248 ; Lympho- sarcoma, 305 Bednar's Aphthap, 85 Belehat, Roland de. Ankyloglossia, Acquired, 50 Bell, B. Excision at end of Eighteenth Century, 353 Benign Tumours, 280 IK-nnett, H. Glo>soplegia by Malignant , Growth. 42.". Berger. Sarcoma, 303 ; Spasm, 431 Bernliardt. Xerostomia, 412 Bernays. Thyreoglossal Tumour, 251, -'">4 Berry. Cartilaginous TuiiKJur, 2S6 ; Nutrient Enemata, 407 Bei trand. Polypus removed by Double Liga- ture, 353 Bieshaar. Excision of a Tumour, 352 Bind Tongue, _.' Billroth. Division of Jaw in Excision, 365 Birkett. Glossoplegia from Glandular En- largement, 427 Bites, 43 ; of Insects and Snakes, 42 Black Marks in Addison's Disease, 02 Black Tongue or Hyperkeratosis, 14"> Blanc. Fibromyoma. 2*4 Blandin. Gland of, 9; Congenital Hypertrophy of, 225; Cyst, Ranula in, 233 ; Raphe of Tongue, 12 Ble\ thing. Traumatic. Ulcer, called Sarcoma, 300 Blood Cysts, 244 ; Blood Stains, 63 Bloodgood. Sarcoma, 308 Bnrhdalck. Thyreoglossal Tract, 3 Boddington. Ankyloglossia, Acquired, 50 Bn-ckel. Hyoid Bone Tumour, 203 Bo.'kel. Division of Jaw in Excision, 305 Boncourt, Chamisso de. Thyreoglossal Tu- mour in a Cretin, 253 Bond. Lipoma, Diffuse, 283; Preliminary I.aryngotoiny, 372 Bnstroiu. Actinomycosis, 184 Bottini. Galvano-ecraseur, ;{01 Hoiirdette. Kxcessiv.. Mobility, Acquired, 52 l!raci|iiehaye et Sabrazes. Sniilingnal Gland II\ pertrophy. 22"> 470 DISEASES OF THE TONGUE. Brault. Macroglossia, 2r_> Bridou. Wandering Hash, 95 Bristow. Neiircctomy, 418 Broca. Cysticercus, 245 Brown. ToitL'iie, 58 Bruck. Muscular Macroglossia, 277 Bryant. Aneurysiii by Anastomosis, 888; Blood Cyst, 244; Thyreoglossal Tumour, 251 Buccal Excision, 367 Bull. Excision Tuberculous Ulcer, 182 Bullet Wound, 4H Bumstead and Taylor. Mucous Patches. 195 Burns, 39 Burton. Fatal Haemorrhage after Division of Freenum, 31 Buttner. Removal of a Fleshy Growth, 3")-.' Buxdorf. Excision of a Cancer, 352 C. Calculus, Salivary, 236 Cancer, s-:e Carcinoma Cantharides, Ertect of, 40 Carbolic Acid, Effect of, 40 Carcinoma (Cancer, Epithelioina), 309 ; Age and, 311 ; Atrophic, 323, 329 ; Causation, 314; Causation, Caustics, 31(5; Causation, Tobacco-chewing and Smoking, 315 ; Com- mencement of, 325 ; Course of, 329 ; Cures following Excision, 39(5 ; Development of, 317 ; Diagnosis of, 310 ; Microscopic Diag- nosis of, 342 ; Syphilis, Diagnosis from, 341 ; Tubercle, Diagnosis from, 343 ; Dissemina- tion of, 337 ; Diffuse, 323 ; Double, 828 : Epithelial Columns forming, 325; Ex- cision, After-treatment, 376 ; Excision at Two Operations, 381 ; Bilateral Excision, 374 ; Buccal Excision, 307 ; Excision, Cheek Divided, :i81 ; Cures after Excision, 396; Deaths after Excision, 392 ; Ex- cision, Ecrasenr Methods, 360 ; Excision, Early Methods. 346; Exlra-buccal Ex- cision, 378 ; Kocher's Excision, 378 ; Excision, Von Langenbeck's, 385 ; Recur- rence after Excision, 398 ; Excision, Regnoli's Method, 386; Excision, Results, 392; Unilateral Excision, 373; White- head's Exi-ision, 367 ; Fibrous, 323, 32!' ; Fissures, 344 ; Floor of Mouth, 324; Glands- infected Early, 336 ; Histology of, 325 ; Historical Differentiation of, 347 ; Hyper- trophic, 324 ; Incidence of, 309; Inherit- ance of, 314; Fcetor, Inoperable, in:,; Haemorrhage, Inoperable, 408 ; Hunger, Inoperable, 406 ; Glands Breaking Down, Inoperable, 409 ; Nerve Division, Inoper- able, 403 ; Vain, Inoperable, 402 ; Pallia- tive Treatment, 400; Salivation, 404; Termination, 335 ; Leukokeratnsis, or Lencoma and, 116, 318; Local Char- acters of, 339 ; Medullary, 327 ; Meta- static. 339 ; Microscopic Examination for Diagnosis, 342 ; Nest Cells, 327 ; Objec- tive Characters, 322 ; Papillomatous, 318 ; Precancerous or Potentially Cancerous Conditions, 318; Position or Seat of, 310 ; Post-mortem Cases, 390 ; Rank of Life, 313 ; Salivary Calculus and, 237 ; Seirr- hous, 323, 329 ; Secondary, 339; Smoking and, 315 ; Syphilis and, 315 ; Varieties, 321 ; Warty, 318 Cane, Du. Acute Ranula, 235 Capillary Nievi. 2>9 Carter, V. Leprosy, 183; Venous Nievus. 291 Cartilaginous Tumours, 285 Caspary. Wandering Rash, 97 Castel, Du. Leucomatous Patches with ll>-ali d Lupus, 14") Causes of Death after Excision, 394; of Car- cinoma, 314 Caustics causing Carcinoma, 316 ; Stains with, 64 Cavernous Tumours, 29(1 Celsus. " Diseases and Surgery of the Tongue," 349 Cerebral Congestion and Varicose Ranine Veins, 44 Chain Ecraseur, 361 Chalk. Macroglossia, 271 Chancre, Hard, 188; Soft, 189 Chappie. Cancer in Man aired Twenty-four, 312 chassaignac. Chain Ecraseur, 361 Chavasse. Lipoma, Multiple. 2S2 Cheek, Division of, in Excision, 381 Choisy. Glossoplegia by Hydatid Cyst, 425 Chomel. Lingual Rheumatism (so-called), 412 Chondroma, 285 Chorda Tympani Nerve, 24 Chromic Acid to Mucous Patches, 197 Chronic Abscess, 246; Superficial Glossitis. 114 ; Ulcer, 157 Church. Ichthyosis and Hypertrophied Skin Papilla, 144 Ciaglinski and Hewelke. Black Tongue, 14(5 Ciliated Epithelium in Thyreoglossal Cysts, 260 Cirsoid Aneurysm, 288 Clarke, F. Tearing out of the Tongue. 52 Clarke, W. B. Blood Cyst, 244 Clefts. 151 Cloquet. Strangulating Ligature passed from below the Jaw, 355 Clutton. Macroglossia, 270 Coated Tongue, 57. Colby. Acute Abscess, 74 Colleville. Plaques and Seborr',io;ic Eczema, 144 Comparative Anatomy, 1 Congenital Defects, 26 ; Tumours, 280 Contagion of Syphilis from Mucous Patches 194 Cooper. Punctured Wound, 47 Corrosive Poisons, 40 Craigie. Lingual Tonsil, 248 Cramp, 428 Cretinism and Muscular Macroglossia. 2,i' Croly. Anomalies of Lingual Artery, 19 Curtis. Black Tongue, 147 Curtis, H. J. Salivary (Hand Tumour, 229 Cysticercus Cellulosa-, 245 Cysts, Blood, 244 ; Dermoid, 239 ; Foramen Caecum, 251 ; Hydatid, 245 ; Hyoid, 256 ; Mucous, 244; Parasitic, 245; Salivary, Rannlaa, 231 ; Thyreoglossal, 251 D. Darier. Tuberculous Papilloma, 174 Davaine. Guinea-worm, 185 Death after Removal of Tongue, 392, 395 Degle. Glossodynia Exfoliativa, 411 Deinarquay. Atrophy following Ligature of Linguals, 363; Deep Chronic Glossitis. 165 ; Furrows, Inflammatory, 107 Dental Fissure's. |.,| : Nodes, 158; Ulcers, li'i Dentu, Le. Gumina of Hyoid Bone, 263 Dermoid Qjrats, 889; l-'istula-. 212 Despres. Arterio-venous Aneurysm, 288 Development of Tongue, 2; Arrested, 27 Dickinson. Fur, 55; Blue Stain, 64 Dickson. Varicose Ranine Veins. 65 Dieffenbach. Division of the Fnenum for Stammering, 32, 363 Diphtheria. S2 Discolorations of Tongue, 61 L\ni-:.\. 471 Dislocation of Hyoid I: . 2(12 Dissecting Glossitis, KIT Doehmann. Spasm, 430 Dollinger. Macro-lossia following Division of Fneninn, :',-, 2ii5 Dotted Tongue, 57 Driiciiiicultis, Is.'j Dry Toll-lie. 68 Dnbrncii. Neurectomy, 418 Duckwortli. llenii'jld^iti.s, T'.i Ducrey-Unna. Bacillus of soft Chancre, im Duplaix. Enlarged painful Papilla, thi Duplouy. Arrested Development, -^ Durham. Thyivoglossal Cysts ami Fistula-, 2(50 Dyspeptic Excoriations, 59, 102 ; Ulcers, ir.n Earle. Cancer and Syphilis, 347 Ecchyinosis, (>3 Echinoeoceus Cysts, 245 Iv-rasenr Methods, 3t>0 Eickenimsch. Muscular Moorogloasla, 277 Klepliantiasis. .SIT Macroglossia Elliot, llyoid Hone. Nodes and Gummata, 868 Embryology. 2 Emery and Sabourand Soft Chancre, 190 Hnchondrouia, 2*5 Endothelioma, Salivary (Hand 'I'lHiidurs. 22ii Eliidcmic I'listular Stomatitis. '.<:', Epidermal Cysts, .sec DiTimiid, 2:!'.i Epithelinma. tee Carcinoma Epitlieliiiin Anatnniy, 13 Epizootic' Stomatitis. ;M Erythema Migrans, '.H Elkridxe and Rogers. ( ilossople^'ia, 4'2'2 Eve. Black Tongue, 147 ; Maero^lossia. -Jit* : Sarcoma t'ollmvin^ Lymphangiectasis. :;m, Excoriations, 102, 150 F. Facial Artery, 1!> Fairbairn. rsinkinj; back ol'Toii^tie, 35 Fatty 'rumour. -_'s| Fayrer. Aneurystn by Anastomosis, -Js.s ; Maerojilossia. -J73 Fere. Dissemination of Cancer, 338 Fei-^nsnii. Cancer and Syphilis, 347 Fibroma, Fibrous, Fibrocellular Tumour, 388 Fibromyoma, 2S4 Fibrous Carcinoma, 323, 32! Fiildes. Excision with Scissors, 3(50 Filaria Medinensis, 1S5 Fissures, 151; Carcinnmatous, 152, :itl; Dental, 151 ; Syphilitic, 213 ; Tubercu- lous, 171! Fistula, Dei-moid, -J42 ; llyoid, Thyreoglossal, 801 Fleischmann's Uursa, Non-existent, 10 Floor-of-mouth Carcinoma, 324; Excision, Von LanK'-nlicck's. ::*:> ; Regnoli's, 38(5; Partial I'reservation of, 388 Flower. Compaiative Anatomy, 2, 11, 13 Foederl. Ranula of Blandin's (Hand. 288 Fci-tor in inoperable (.'anci-r. 40"i Follicles, l,in-ual Tonsil. 1 I, -J|s Follicular Abscess, '-'."HI Foot-and-Month Disease, '.i| Foramen Ca-ciim, 4 ; Cysts and Tumours of, 251 Foreign liodies, 4*. Fork. Tooth embedded, 50 Founder. Elongated Tongue, 37; Chancre, Hard, l.vs ; .Snil, UMijSelero.sing (ilossitis, Tertiary l'la(|iies, 2ul ; WancienngRash, !>7 Fowler. Discoloration in Addioon's Disease. 69 Forrhage after Division. 31 ; .\Iac-roglossia following. 'Jii'i ; Su-allowing of Tongue after, 31; Treat- ment dl Accid.-nis, 88; .Method of Divid- ing, 32 : Dicers or. 1.17 Francis. .Mac.rnglossia, 2ii7 French. Acute Ranula, 234 Friedland. Follicular Intlamraation. -I'.' Froriep. Hlood-stains in 1'urpura, 63 Funke. Anomalii-s in l y ingual Artery, 19 Fur, Signs connected with, 53; Composition of .\liero-drganisms. 54 Fnrnivall. Dermoid Fistula, 242 Fnrreil Tongue. .,7 Furrows, 105, 150 G. (ialen. Black Bile and Cancer, 34! ; Muscu- lar Maeroglossia, 275 (ialish. Two Th\ rcoglossal Tumours, 254. 25S (ialleb rani and I'aiif.inotti. Spasm, 442 (ialvauo-ecraseur, 361 Gangrene, "i> (iarel. Erysipelas and Streptocoecal Glossi- tis, 72 Garrod. Tongue and Rheumatic Fever, 412 ll;i\. Angioma, I'nlsating. 2ss Cenioliynglossi Muscles divided for Spasm, 441 Ceogiaphioal Tongue. ;u (iibli. Fish-bone in Tongue, I'.' (licit (Von), (iangrene following Cachexia, 77 Gillot. Varicose Ratline Veins, t>5 (iirerd. Mattroglossia, 2ti5 (iirouard. Caustic Treatment of Cancer, 355 Glands, Lymphatic, Anatomy, 21 ; infected by Cancer, 33d; Dissection of, 382 ; Routine Removal, 301 ; inoperable, breaking down, 40'.i; Mucous and Salivary Ana- tomy, 7; Disease, 225 Glandular Tumour, 2!7 Glossalgia, 411 (ilossanthrax, 77 (ilossitis, Acute, (5(5 ; Hsemorrhagic, 74 ; Paren- chymatous, 71 ; Superficial, 79; Chronic Superficial, H4, 114; Diphtheritic, S2 ; Dissecting, 107; Membranous, 82; Mer- curial, 74 ; Staphylococcal, 73 ; Strepto- coccal, 72 ; Tertiary Sclerosing, 201 (Uossodynia Exfoliativa, 109 Qlosaopharyngeal Nerve, 25 (Jlossoplegia, 420 Qodlee, I lisseminated Cancer, 338; Sarcoma, Ulandin's (iland. 2:14 ; Multii>le, 298 Goldmann. Carcinoma spreading by Veins, 334 Goodale. Black Tongue, 14(5; and Hewes' Raw Tongue with Dyspepsia, 104 Gosselin. Hydatid Cyst, 24(1 Gout and Leucoina, 128 Green. Dermoid Cyst, 241 (ireenhow. Pigmentation, (>2 Greenwood. Varicose Ranine Veins, C>5 Grillin. Hard Cliancre. |S9 Gritlith. Arrested Dcvelnpment, 30 Grooves, 105, 150 Gubler. Wandering Rash, 95 Giieterboch. Hemiglossitis, 81 Guinea-worm, 1S5 (iummata, 205 Gummatolis Ulcers, _'_':; Guthrie. Excision of Cancer, 248 (iax/dla. Enlarged painful Papilla-, 41(1 H. Hack. Excoriations, Dyspeptic. In:; 472 DISEASES OF THE TONGI'I-;. Haddeu. Xerostomia, 60, 411 BamaQgioina, ^~ Haemorrhage, Control during Excision, 374 ; Fatal after Division of Fnenum, 31 ; from Wounds, Arrest of, 44 ; inoperable Can- cer, 408; Secondary from Wounds, d, Bemorrhaglc Glossitis, Acute, 74 Hairy Black Tongue, 145 Hall, A. J. Xerostomia, 60 Hall, rte H. Herpes, 111 ; Membranous Glos- sitis, 84 Hamilton. Punctured Wound, 47 Harding. Galvano-ecraseur, 361 Harris. Excision early in Eighteenth Cen- tury, 353 Harrison. Cancer in Girl aged Twenty, ::12 Hayes. Salivary Gland Tumour, -J30 Heath. Compression of Lingual Artery, 375 Heaton. Venous Xaevus, 293 Hebb. Actinomycosis, 185 Hectic, Tongue in, 59 Heidenhain. Cancer passing through Lym- phatics, 332 Heister. Excision of a Scirrhous Tumour, 351 Helbing. Muscular Macroglossia, 277 Hemiatrophy, 421 Hemiglossitis, Herpetie, Nervous, 81 ; Paren- chymatous, 79 Hemiparesis, 421 Hennig. Sinking back of Tongue, 35 Herpes, 101) ; and Skin Affections, 111 Herpetic Hemiglossitis, 81 ; Ulcer, 161 Heyfelder. Anthrax, 77 Hickman. Thyreoglossal Tumour, 251 Hfldanns, Fabncius. On Cancer, 350 lill. Reflex Neuralgia, 417 Hillier. Guinea-worm, 185 Hilton. Division of Lingual Xerve, 363, 403 Hippocrates. On the Tongue, 349 Hirt. Glossoplegia, 422 His. Thyreoglossal Tract, 3 Histology, Pathological, 325 History of Surgery of the Tongue, 346 Hobbs. Tongue-bite, 43 Hoffman. Macroglossia, Excised, 352 Hofmokl. Cysticercus Cellulose, 245 Holthouse. Glossoplegia and Syphilis, 425 Home. Excision by Strangulating Ligature, 347, 354 Hueter. Sarcoma, 300 Hugenschmidt. Composition of Saliva. -V4. 71 Holes. Venous Xamis, 291 Hulke. Syphilitic Chancre, 195 : Ichthvosis 115, 139 Hunger in Inoperable Cancer, 406 Hunter. Skeleton of Tongue, 11 Hutchinson. Black Tongue, 147; Dissemi- nated Cancer, 338 ; Fur on Tongue, .'.4 : Glossoplegia, 427; Herpes, treated by Arsenic, 112; Leucoma, 115; Lichen IManus, 144; Lympho-sarcoma, 305; Membranous or Pellicular Glossitis, 84 ; Macroglossia, 273 ; Sulcated Tongue, 108 ; Wandering Rash, 98 Hutchinson, J., jun. Macroglossia, 268 Hydrochloric Acid, Effect of, 40 Hyoid Bone, Diseases, Injuries, 262 Hyoid Bone, Thyreoglossal Cysts and Tu- mours, 256 Hypersesthesia, 411 Hypergeusia, 419 Hyperkeratosis, 145 Hypertrophic Carcinoma, 324 Hypertrophy, Inflammatory, 279; Lin"iial Tonsil, 250; see Macroglossia. Hypoglossal Xerve Anatomy, 23 ; Cramp 428 ; Paralysis, 420 Hyrtl. Anomalies Lingual Artery, 19 I. IchthyoMs. i:t Idiocy and Muscular Macroglossia, 27ii Illicit. Actinomycosis. |si Imaginary 1'livration. Us Incisive Gland, 10 ; Cyst or Ranula in, 233 Indentations, 14'.' Ingals. Sinking Back of Tongue, 36 Ing] is. Exi ision by Strangulation, 3o4 Innocent Tumours, 280 Iodide of Potash first used, -47 lodoform, 365 ; Dressing, :;':> J. Jackson. Glossoplegia, 422 Jacob!. Angioma, 298 Jacoby. Glossoplegia, 421 Jaeger. Division of Cheek in Excision, 356 James. Secondary Sarcoma, 307 Jaws Deformed l.y .Macroglossia, 270 Jessett. Frequency of Cancer, 30!' Joachim. Tongue-tie, 32 Johnson. Thyreoglossal Cyst. 2"i2 Jurist. Acquired Excessive Mobility, 52 Jussieu. Arrested Development. 27 Kanthack. Thyreoglossal Tract and Tumours, 6, 256 Kaposi. Closso'lynia Exfoliativa, 109, 411 Kappeler. Diagnosis of Salivary Calculus, 287 Keith. Removal of a Fungous Tumour, 360 Kelly. Follicular Inflammation Lingual Ton- sil, 249 Keloid. 2'.7 Keratosis of Skin with Leukokeratosis, 143 Kirk. (Kdema from Primula Ol.onica, 420 Knight. Follicular Abscess Lingual Tonsil, 250 Koch ami Marie. Glossoplegia in Tabes, 424 Kocher's Operation, 378 ; Genesis of, 364 ; Results. :;'.i( Kolliker. Lingual Tonsil, 14 Kiiinlein. Results of Excision, 394 Kiittner. Lymiiliatic Glands Removal. 21, 333; Salivary Calculus, 237 L. Laborde. Rhythmic Traction Exciting Re- spiration. 2". Lane. Salivary Gland Tumour. 22'. i Lang. Cartilaginous Tumour. _'> Lange. Spasm, 440 Lannelongue. Cysticercus Cyst, 245 ; Ranul Congenital, 2:52 Laryngotomy Preliminary to Excision, 372 Lawrence. Leukokeratosis, 115 Lead Causing Glossoplegia. 42:: Lecoarret. Patches with Simple Psoriasis, 145 Lediard. Black Tongue, 14f, Legg. Hiemopliilia, Fatal Bite, 43; Xan- tliclasina, ill INDEX. 473 Lcwin and Heller. Syphilitic Atrophy, 204; Svphilis ami Gl.issoplc^ia. l'_'l . ;-. Kettex . \ii.i< mem-otic -al Cy-l. _'.' .icheii (if tin- Ton-tie, 144 Jndiier. Tongue Sucking, 30 Jngard. Xoina, 77 .ingua prop.-ndula vol vituli, 264 Lingual Artery Anomalies, is ; Anatomy, r> ; Ligature for Inoperable Cancer, 400 ; Ligature, Muscular Macroglossia, 277; _it me. Preliminary, 3. r iti. 3-V.i ; Lijja- ture to Produce Atrophy, 3iB ; Nerve Anatiiniy, -J4 : Xcr\c Divided for Pain, 4itt, 417: Neuralgia. 411; Quinsy, -;*: Tonsil, 14, 24s; Tonsil Hypertrophy, J.'iii : Veins, 20 Lipoma. -_'M Lissauer. Patches \vitli Simple Psoriasis, 14"> Listun. Maeroxlossia. I'ya-mia after F.x- cision. :; I s Unit-wood. Malignant Sardinia, 304 l.oenmotor Ataxia. Atrophy, 422 Louis. Memoir on the Tongue, 353 I.outli. Anomalifs of Lingual Artery, 19 Lucas. Stretching Lingual Xi-rvt-. 11^ Ludwig's Angina, 72 Lupous Ulcers, 174 Lupus, sec Tuberculosis Lympliadenonia and .Miu-ro^lossia, 207 Lyniphaii^iectasis and Macroglossia, 2(>ti I.yiiiiihan<,'ioina, 2(55, 273 Lymphatics Anatomy, -1 Lymphatic Follicles, Anatomy, 14 ; Glands, Anatomy, 21 ; Glands, Carcinomatous, 330 Lymphatic XH-VUS, see Lympliangioma Lympho-sarcoina, 305 M. Maas. Macroglossia, 272. u'77 .MacC.innick. Cancer, Secondary (?), 339 .Mackenzie. Glossitis, 69; Glossoplegia, 423 Macroglossia, Lymphangioniatuiis, 2t>4 ; Karly Cases, see Chap. XIX. ; Inflammatory, 27-'. ; M.-rcmial. 27: ; Muscular. J78 : Syphilitic, 27 < Maguire. Mat-roglossia, 272 Maissoneuve. Caustics for Cancer. 355 Ma jcndie. Early Use of lotlide of Potassium, 347 Major. Excision by Strangulating Ligatures, 355 Makuen. Fnt-num Divided for Stammering, Makuna. Tongue Bite, 44 Malformations. LV. Marehetti, Petrtis de. Tumour Removed, 351 Mavi'scotti. Excision of a Cancerous Ulcer, 351 Marion. Sarcoma, 299 Marshall. Galvano-Ecraseur, 3(51 Masticatory Spasm, 433 Maurent. Macroglossia, Jaw Displaced, 352 Maydl. Actinomycosis, 185 Major. Traumatic Glossoplegia, 427 Membranous Glossitis, 82 Mendel. Capillary Xa-vus, 2SO ; Gangrene following Syphilis. 7t> Mi-nonista, Petrus. Excision of a Tumour, 351 Meicier. PedoncaUted Fibroma, 300 Mercurial Glossitis, 74 ; Hyjiertrophy or Macroglossia, 279 ; Ulcers, Ms Merkel. Incisive (Jland, 10 Mever. I.ympho-sarcoma, 30ti Miclielson. Herjjes, 110 Micro-organism in Moutli, "1 Middledorptf. (ialvano-Kcraseur, 361 Mikulicz. lodoform Dressing, 365 ; Sarcoma, 303 Mikulicz and Kummel. Anthrax, 77 ; Chon- tlroina. 2sii Mikulic/ and Miclielson. Bednar'g Aplith;i-, 85 ; Sarcoma, 300 Miller. Trichina, 18<5 Miiault, G. Preliminary Ligature of Lingual, Mirault, J. F. Macroglossia, 271, 356 Mitchell. Spasm, 43f. Mobility Excessive, Aci|uiied,52 ; Congenital, 33 Mollii-re. Cysticercus Cellulose, 24."> Monod. Lijioma, 282 Moore. Division of Lingual Xerve, 403 Morcstin. Ranula, 233 Moriarty. Malarial Cachexia, 77 Morphine for Inoperable Cancer, 402 Morrison. Traumatic Glossoplegia, 42"i Morrow. Leukokeratosjs and Selwrrhieic Eczema, 143 Mott. Aneurysm hy Anastomosis, 289 Motte, De la. Excision of Pefluni-ulateil Tumour, 35 Mucous Cysts, 244 ; Glands, Anatomy, 7 ; Patches, Chromic Acid for, 197 ; Patches and Syphilitic Contagion, 194 ; Patches and Tubercle, 191 Mumps affecting Submaxillary or Sublingual Gland, 22ii Muscular Sense, Disturbances Causing De- fective Speech, 420 Mussy, De. Hemiglossitis, 80 Myguid. Acute Hsemorrhagic Glossitis, 74 Myxo-tlema following Removal of Thyreo- glossal Tumours, 254 N. Xaegeli. Transnxion by Tooth, 44 Xa-vus, 289 Xedopil. Leucoma, 133 ; Tubercle and Cancer, 343 Xeligan. Leucoma, 132 Xerve, Division of Lingual, for Pain, 403 Nerves, Anatomy of, 23 Xervous Hemiglossitis, 81 Nest Cells in Epithelioina, 327 Xeumann. Ciliated Epithelium of Foregut, 6 Neuralgia, 411 Xigrities, 14. r > Xitric Acid, Effect of, 40 Xodes and Nodules, 153; Syphilitit , 2ertrophied Lingual Tonsil, 2w Operations, Classical and Early, 34( Operations of Excision, 367 Osseous Tumours, Osteoma, 2->" Ostuani. Galvano Ecraseur, 3ti2 Oxalic Acid, Effect of, 40 P. Paget, Sir J. Carcinoma Microscopic Struc- ture, 347 ; Fibroma, 284 ; Glossoplegia, 42."i ; Ranula, Old Enonnou*. 23."> ; Smokers' Patch, 121 Paget, S. Dermoid Cyst, 241 ; Ranula, Con- genital, 233 Pain in Inoperable Cancer, 402 Palliative Treatment of Cancer. 400 474 DISEASES OF THE TONGUE. Papilla;, Anatomy, 13; Congenitally Enlarged, 38; Foliate, Painful, 413 Pai>illoiiia, -293 ; and Carcinoma, 318 ; follow- ing Leucoma, 294 ; Tuberculous, 174 Parageusia, 419 Parasitic Cysts, 245 Parsesthesia, 418 Paralysis, Hypoglossal, 420 Pare, Ambrose. Division of Frsenun:, 31 , 350 ; Suture of Wound, 350 Parker, B. Thyreoglossal Tumour, 256 Parrot. Muscular Macroglossia, 277 ; Wander- ing Rash, 97 Pasquier et Marie. Nervous Semeiology, 410 Patches, 152; Excision of, 139; Leucoma- t'His, with Skin Attections, 143 ; Mucous, I'.tl ; Smokers', 116 Pemphigus, 111 Pendl. Rhabdomyoraa, 285 Perkins. Macroglossia, 268 ; Sarcoma follow- ing Lyniphangiectasis, 307 Pernian. Lingual tonsil Hypertrophy, 299 Petit. Tongue-swallowing, 32, 33 Phagedena, 76 Pigmentation, 62 Pimpernelle. Removal of a Gangrenous Tongue, 347, 351 Plaques (see also- Patches), 152; Tertiary Syphilitic, 198 Poisons, 40 Potash, Effect of, 40 Potter. Tooth embedded, 50 Powell. Acquired Ankyloglossia, 51 Power. Large Salivary Calculus, 237 Pre-cancerous Conditions, 318 Preehard. Hydatid Cyst, 246 Pritchard. Gangrene, 76. Prolapsus Lingua-, 270 Protrusion, Rhythmic, 431 Psilosis, 61 Psoriasis, Simple, on Skin and Tongue, 145 Pnzey. Large Salivary Calculus, 237 Quinsy, Lingual, 248 Q. R. Rammstedt. Anthrax, 78 Ranine Veins, Varicose, 64 Ransohon". Excision of a Leucomatous Patch, 139 Ranula, 231 Raphe" Development, 10 Raw Tongue, 59 ; Excoriated Tongue, 102 Raymond and Artaud. Glossoplegia and Tabes, 423 Reboul. Haemorrhage, Fatal, after Division of Franum, 31 Recklinghausen, Von, and Sonnenberg. Ranula, Blandin's Gland, 233 Red Tongue, 59 Regnoli's Operation, 357; Extended, 386 Reinbach. Capillary Nsevus, 289 Reintjes. Myxadema after Removal of a Thyreoglossal Tumour, 254 Remak. Lead causing Glossoplegia, 423 ; Spasm, 432 Removal, see Carcinoma Reptiles, Bites of, 42 Rhabdomyoma, 285 Rheumatism, Lingual (so-called), 412 Ribbert. Macroglossia, 274 Richet. Acute Ranula, 234; Hydatid Cyst, 246 Rigal. Discolorations, 64 Riga's Disease, 294 Ringworm of Tongue, 94 Rokitansky. Carcinoma, Microscopic Struc- ture, 347 Rosenthal. Pemphigus, 111 Roser. Cysticercus Cellulose, -24i> ; Division of Lingual Nerve, -418 Routier. Acquired Ankyloglossia, 51 Roux. Excision of Half the Tongue, 359 S. Sa brazes and Bousquet. Streptococcal Glossi- tis, 72 ; and Cabanr.es, Muscular Macro- glossia, 277 Salivary Glands, Anatomy, 7 ; Calculi, 236 ; Hypertrophy, 225; Obstruction Cy-t-. Ranula, 231 ; Tumours, 22(5 Salivation in inoperable Cancer, 401 Salter. Traumatic Glossoplegia. 4-_v, Sangster. Chronic Superficial Glossitis, 115 Sappey. Lymphatics and Glands, 21 Sarcoma, 298 ; Benign Forms, 301 ; Diagnosis and Treatment, 307; Lyniphangiectasis and, 306; Lymphosarcomas, 305; Malignant, involving Glands, 302 ; Secondary, 307 ; Tumours not proved to be, 298 Scalds, 41 Scar, Hypertrophied or Keloid, 297 Scheier. Lymphosarcoma, 30(5 Schiffer. Traumatic Glossoplegia, 426 Schmidt. Amyloid Tumours, 286; Noma, 77 Schulten. Lymphosarcoma, 306 Schiitz. Patches with Simple Psoriasis, 14.", Schwimmer. Leukoplakia, 115 Sclerosing Glossitis, 201 Sedgwick. Keloid, 297 Sedillot. Acquired Ankyloglossia, 51 ; Divi- sion of the Lower Jaw, 359 ; Macro- glossia, 3-.', 2ii.l Seiler. Bristle embedded, 49 Seldowitch. Myxoedema following Removal of Thyreoglossal Tumours, 2~>4 Semeiology, 53 Sendziak. Black Tongue, 146 Senile Tongue, 60 Sensation, Disturbances of, 410 Septours. Tripartite Tongue, 29 Septum Development, 10 Shepherd. Anomaly in Lingual Artery, 19 Shillitoe. Cysticercus Cellulosse, 245 Shimmer. Nitrate of Silver Stain, 64 Shrunken Tongue, 58 Siebold. Macroglossia, 271, 348, 352 Siegel. Foot-and-Mouth Disease, 91 Signs of Disease, 53 Sinking Back of the Tongue, 35 Skin Affections and Herpes, 111 ; and Leu- coma, 143 Sloughing of the Tongue, 76 Smoker's Patch, 116 Smoking and Cancer, 315 Smooth Tongue, 140 Snakebite, 42 Soda, Effect of, 40 Soliber. Hard Chancre, 189 South. Acquired Ankyloglossia, 51 Spasm, 428 ; of Larynx from Depressing Tongue, 36 Spisharny. Hyoid Bone Tumours, 263 Split Tongue, 29 Sprue, 61 Stains, 64 Staphylococcal Glossitis, 73 Stammering, Stuttering, Division of Frsemun for, 32, 363 Stetten. Hyoid Bone Abscess, 263 Stings, 42 Stippled Tongue, 57 Stiihr. Lymphatic Follicles. 14 Streckeisen. Accessory Thyroid Bodies. 6, 256 Streptococcal Glossitis, 72 INDEX. 475 Stromeyer. Mercurial Glossitis, 75 ' Stiidcnski. Congenital Tumours, 280 SulilinLUial Gland, see Salivary Glands Submaxillary Claud, see Salivary Glands Sulcated Tngoa. 150 Sulphuric Acid, Effect of, 4o Superior Laryngeal Xerve, -j.". sinvry. Early. :('. : Present-day, 367 Sutton". Dermoids, 240 Suzanne. Incisive Gland, 10; Myxoniatous Degeneration causing Kanula, 232 Swallowing of Tongue after Division of Fr.fniiin. :il Syme's Cases of Excision, 348 Syphilis, Atrophy, 204 ; and Carcinoma, 31. "> ; Chancre, 188 : Contagion from Chancre, 189: Mucous Patches, 104 ; Fissures, 213; Generalised. Secondary, ISM; Tertiary Gummata, :><>."> ; about Hyoid Bone, MB; Hypertrophy, 21s ; (fade*, Xodules. 204 : Plaques, US; Tertiary Sclerosiiisj Glossi- tis, 201 ; Ulcers, 219 T. Targett. Sarcoma, 304 Taste, Disturbance of, 410 Teeth, Fissures due to, 151 ; Nodes due to, 153 ; Ulcers due to, 104 Tenneson. Macroglossia, -71' Thin. Sprue, 61 Thomson. Dyspeptic Neuralgia, 412 ; Smoker's Patch becoming Tuberculous, 145 Thrush, S4 Thyreoglossal Cysts and Tumours in Tongue, 251 ; about Hyoid Bone, 25(5 ; Tract, De- velopment, * Thyrohyoid Bursa, not Distended, 260 Tinctorial Discolors tious, 64 Tongue-swallowing, 33 ; -tie, 30 Tonsil (Faucial) and Palate involve.! hy Carcinoma, 385 Tonsil, Lingual. 248 Tracheotomy, Preliminary. 372 T ravers. Cancer and Syphilis, 347 Tremor, 42s Trevelyan. Glossoplegia, 421 Treves". Aci|ilire ; Salivary, 226 ; Sarcomatous. see Sarcoma, 200 ; Thyreoglossal or Thy- roid. 2.M Turner, D. Calculus Removed from a Ranula, 353 Turner, G. R. Syphilitic Glossoplegia, 424 Tvlosis, 115 U. Uhlmann. Hyoid Bone Injury and Disease, m Ulcers, Aphthous, 153 ; Cancerous, see Car- cinoma ; Chronic, 157 ; Dyspeptic, 160 ; Freenum, 167 ; Herpetic, 161 ; Imaginary, 41s; Lu pous, 174; Mercurial, }- Simple, 155 ; Traumatic, 164 ; Syphilitic, 21'.' ; Tuberculous, 170 Unna. Wandering Rash. ;>7 V. Valenta. Macroglossia, 272 Vallin. Spasm, 441 Vanlair. Wandering Rash, 09, 101 Varicose Veins,- Base of Tongue, 250; Veins Ratline, 64 Variot. Cancer in Boy, aged Eleven, 312 Vascular Tumours. 2s7 Vasomotor Disturbances, 41;' Vausaiit. Acquired Ankvloglossia. 51 Vausetti. Resection of Lingual Xerve, 418 Vicary. Canker in the Mouth, 351 Veins of Tongue, 20 Venous Xaevi, 200 Vergal. Laryngeal S|>asm from Depressing Tongue, 36 Venion. Maeroglossia. 27.", Virchow. Structure of Carcinoma, 347 ; Lymphangioinatous Maeroglossia, 263, m ; Syphilitic Atrophy, 204 Volkmann. Endothelial Salivary Tumours, 22f> V-shaped Incision, 373 Vulcanite Tooth-plates and Leucoma, 126 W. Waite. Galvano-ecraseur, 361 Wala-us. Removal of a Tumour, 351 Walsham. Division of Lingual Xerve, 41S Wandering Rash, i>4 Wart", 203 Warty Tumour, 203 Wash bourn and Goadby. Micro-organisms of Mouth, 71 Wasted Tongue, 60 Waterhouse. Thvreoglossal Cyst, 359 Weber. Chondroma, 285 ; Development Arrested, 27 ; Epidemic. Acute Glossitis, Weir. Excision for Tuberculosis, 182 West. Treatment of Thrush, !>0 Wetmor,'. Follicular Abscess, Lingual Tonsil, 250 Whartiin. Diphtheria, s:i Wharton's Duct, Obstruction of, 234 Whetry. Acquired Excessive Mobility, 52 Whipcord Eciaseur, 362 Whitehead's Operation, Genesis of, 364 ; or Buccal Operation, 367 ; Results, 393 ; Varnish, 375 Whitehouse. Varicose Raniue Veins, 65 Whooping Cough, Ulcers of Fr.vnum in, 1(17 Willan. Pemphigus, 111 Williams. Carcinoma : Posf-mortem Cases, 390 Winiwarter, Von. Macroglossia. 272 Winslow. Acquired Excessive Mobility, 52 Wiseman. Two Cases of Cancer, 34<> Wolff. Thyreoglossal Tumour Removed, 258 Wood. Dislocation of Hyoid Bone, 262 Wounds, 43; Bullet, 46 ; Deep, Perforating, Wrinkles, 105, 150 Wunderlich. Membranous or Dissecting Glossitis, S4, 107 X. Xanthelasma. ill Xcrstomin, 60 Zeisler. Muscular Macroglossia. '277 Ziegler. Amyloid Tumours, 286 Zuckerkandl. Anomalies, Lingual Arterv, 19 PRINTED BY CASSELL AND COMPANY, LIMITED, LA BfcLLE SAUVAGE, LONDON, B.C. University of California SOUTHERN REGIONAL LIBRARY FACILITY 405 Hilgard Avenue, Los Angeles, CA 90024-1388 Return this material to the library from which it was borrowed. fliHRUBRARY LOAMS NAY 01 A 000510128 2 DC IRVINE LIBRARY I III III I Illl Ill I III 1 1 III II II III I III I 3 1970 01621 5045 WI 210 B987d 1900 Butlin, Henry T. Diseases of the tongue WI 210 B987d 1900 Butlin, Henry T. Diseases of the tongue MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664