In those cases of diffuse inflammation of the interconnective tissue of the genio-hyo-glossi muscles Fleming states that the suppuration—which, whether circumscribed or diffuse, burrows toward the root of the tongue—absolutely dissects its extrinsic muscles and destroys their functions; ultimately injuring the periosteum and laying bare the inside of the inferior maxilla in the vicinity of their attachments. When an incision is made to the parts through the integument, the muscles will be found on palpation flabby and detached, and their interstices filled with purulent matter, sometimes very fetid.
DIAGNOSIS.—These is no difficulty in the diagnosis, except in the early stage of such examples as are attributed to metastatic gout and rheumatism. The subsidence of the peculiar pains elsewhere, and the onset of pain in the tongue, would lead to the inference that a glossitis of this kind was in progress. The acuteness of the tumefaction would distinguish it from hypertrophy of the tongue on the one hand, and from the tumefaction attending malignant disease on the other.
Cystoma of the tongue has sometimes been mistaken for abscess due to glossitis; but even here the history of the case should serve in most instances as a satisfactory factor for the differential diagnosis.
PROGNOSIS.—The prognosis depends upon the gravity of the local symptoms and the activity of the treatment. A case left to itself will be likely to terminate fatally within five or six days. Death, indeed, has been known to take place within forty-eight hours, even in cases submitted to treatment. On the whole, however, the prognosis should be regarded as favorable in the absence of specially lethal complications. Even suppuration adds little gravity to the prognosis, the structure of the organ being but little favorable to accumulations of purulent material. Should an abscess become gangrenous, however, the prognosis becomes grave at once, as it in the presence of gangrene from pressure or other cause. Should the patient survive losses by gangrene, there may be permanent impairment in articulation.
TREATMENT.—Superficial glossitis, as a rule, merely requires active purgation, with the topical use of cold emollient mouth-washes containing mucilage of slippery elm, quince-seed, or the like, to which detergents, such as alum and borax, may be advantageously added in the proportion of five grains to the ounce. In cases resisting this mild treatment topical applications of glycerite of tannin twice or thrice a day are often serviceable.
Parenchymatous glossitis demands the most active antiphlogistic treatment. If the case be seen at an early stage of the process, before the tumefaction of the tongue has become so great as to fill the mouth and interfere with swallowing, a saline purge—say salts and senna—containing some tartar emetic can be advantageously administered to begin with. Following this, tartar emetic may be continued in small doses every two or three hours, associated with small doses of tincture of aconite-root (minim j-iij), according to the condition of the pulse and the effect of medication. Should this treatment fail to produce prompt amelioration in the local symptoms, or should the tongue be considerably swollen when the case comes under care, free leeching should be applied from the hyoid bone to the angle of the jaw on each side, including the region of the hyoid bone (fifteen to twenty-five Spanish leeches). This should be followed by emollient cataplasms, reaching from ear to ear, to favor continuous hemorrhagic oozings from the leech-bites. The internal antiphlogistic treatment is indicated just the same, and if not administrable by the mouth may be administered by the bowel; the nauseant and depressent effects of the tartar emetic and aconite being maintained by hypodermatic injection. Leeching the inflamed tongue itself is said to be often prompter in producing detumescence of the organ than leeching exteriorly, but the leech-bites are apt to add to the local irritation; besides which, the mouth is so filled by the swollen tongue as to leave little more than the tip accessible to the leeches without danger of losing control of them. Venesection from the arm, the jugular vein, or from vessels elsewhere is no longer much in vogue, it being doubtful whether general venesection is more useful than local bleedings. Debility, whether presenting originally or as the result of withdrawal of blood and other antiphlogistic measures, may be met by the systematic use of tincture of chloride of iron and of quinia.
Severe cases demand one or more longitudinal incisions on each side of the raphé of the tongue, deep enough to reach nearly halfway into the substance of the organ and carried from base to tip. Cases are on record in which the patients themselves had in their despair cut into their tongues in order to obtain relief from their local sufferings, and had in this way rescued their own lives by the means most appropriate for the purpose (Camerarius, Lusitanus69). When the mouth is filled by the tongue, it is necessary to insert the knife on the flat until the base of the tongue is reached, and then to turn it and make the cuts as indicated. Copious bleeding usually follows these incisions, often followed by marked diminution in the volume of the organ. Deep as these cuts appear when made, they become quite shallow before the organ has shrunk to its normal volume. Bleeding from the ranular veins, recommended by some practitioners in preference to incisions into the organ, is often impracticable on account of the tumefaction preventing access to them.
69 Dict. Sciences méd., vol. xviii.
If severe hemorrhage takes place from divided vessels, the vessels may be subjected to torsion, which is the preferable mode of management, or to searing with some form of the incandescent cautery (hot iron, electric cautery, Paquelin's thermo-cautery). Astringent and chemical styptics are of little use. The method of searing is open to the objection that secondary hemorrhage may ensue on detachment of the eschars, but this accident is not likely to happen under circumstances at all favorable.
In localized or circumscribed glossitis the incision to be made should interest the swollen portion only.