A gumma is usually situated on the dorsum and more often towards the centre than at the edges. As it seldom implicates the floor of the mouth or the base of the tongue, the tongue can usually be protruded freely. It forms an indolent swelling, which tends to break down slowly and to ulcerate. So long as it remains unbroken it does not cause pain, and there is no enlargement of the adjacent lymph glands. Two forms are met with—the superficial, and the deep or parenchymatous.
A superficial gumma appears as a small hard nodule under the mucous membrane, varying in size from a pin's head to a pea. The mucous membrane over it is redder than normal, and in the early stages retains its papillæ but later becomes smooth. It tends to break down early, forming a superficial ulcer. Superficial gummas are often multiple.
The deep or parenchymatous form varies in size from a hazel-nut to a walnut, and feels like a hard body in the substance of the tongue. The mucous membrane over the swelling is of normal colour, but is usually devoid of papillæ. The gumma may remain for months unchanged, or may approach the surface, soften, and break down, leaving a deep, ragged ulcer.
Syphilitic ulcers and fissures are nearly always due to the softening and breaking down of gummas. The ulcers have seldom the typically rounded or serpiginous outline of gummatous ulcers on other parts of the body. The base is ragged and unhealthy, and on it a yellowish-grey slough resembling wash-leather may be seen. The edges are steep, ragged, and often undermined, and the surrounding parts thickened and indurated. The neighbouring glands are not usually enlarged. The ulcer is extremely painful when irritated by food, hot fluids, or spirits. If untreated, the sore may remain indolent and for months show no sign either of spreading or healing, but at any time it may become the seat of cancer.
Syphilitic fissures are met with as long, narrow, deep clefts, or as stellate or sinous cracks in the substance of the tongue. After the healing of these ulcers and fissures permanent furrows and depressed scars remain.
Treatment.—The tertiary manifestations of syphilis in the tongue are treated on the same lines as other tertiary lesions. Locally, the use of mouth-washes, such as chlorate of potash or black wash diluted with lime-water, the insufflation of powdered iodoform and borax with a small quantity of morphin, or the application of mercurial ointment is useful. The sore must be thoroughly cleansed before these remedies are applied.
New Growths
Carcinoma is by far the most common form of new growth met with in the tongue, and it is almost invariably a squamous epithelioma.
Epithelioma generally occurs between the ages of forty and sixty, and attacks males oftener than females, in the proportion of about six to one. Its development is favoured by any long-continued irritation, such as the rubbing of the tongue against a carious tooth, an ill-fitting tooth-plate, or the rough end of a short clay pipe, particularly when such irritation leads to the formation of an ulcer. Chronic superficial glossitis associated with leucoplakia, and syphilitic fissures, ulcers, or scars, also act as predisposing factors. The repeated application of strong caustics to chronic inflammatory conditions is, according to Butlin, a determining cause of cancer. The degree of malignancy appears to vary in different cases, and is probably lowest when the disease originates in a patch of leucoplakia or other pre-cancerous lesion.
The disease is usually situated in the anterior half of the tongue, and more commonly on the edge than on the dorsum. It may begin as an excoriation, ulcer, or fissure, or as a warty growth, particularly in association with a patch of leucoplakia. In all cases ulceration begins early, and the base of the ulcer and the surrounding parts become indurated. The lymph glands are, as a rule, early infected.