A Pathological Change at the Base 
of the Tongue, Possibly Explain- 
ing Certain So-Called Func- 
tional Diseases of that 
Organ. 
MY 
C. W. RICHARDSON, M.D., 
OF WASHINGTON, D. c. 
Read before the Medical Society of the District of Columbia, 
October io, r888. 
Reprinted from the “Journal of the American Medical 
Association,” January 26, 1889. 
CHICAGO : 
Printed at the Office of the Association. 
1889. A PATHOLOGICAL CHANGE AT THE 
BASE OF THE TONGUE, POSSIBLY EX- 
PLAINING CERTAIN SO-CALLED 
FUNCTIONAL DISEASES OF 
THAT ORGAN. 
During the last decade the advance in laryngol- 
ogy has been so great that the number of cases of 
nervous origin, or functional, has been so vastly 
reduced that the so-called nervous and hysterical 
cases are becoming rather limited in their number. 
It has only been within this period that attention 
has been called to several important pathological 
lesions situated at the base of the tongue giving 
rise to symptoms which seemed never to be re- 
lieved by the methods of treatment previously in 
vogue but now completely cured, enabling us to 
relegate a large number of so-called nervous cases 
to their proper sphere. It is in hope, by calling 
attention to some further changes in this organ, 
of still further reducing the number of nervous 
cases that I present the following paper, We 
recognize, most thoroughly, that there are a cer- 
tain number of cases presenting no pathological 
changes, due seemingly to perversity, that may 
forever belong to this sphere, but that there are 
still a large number that will be withdrawn from 
this field of uncertainty no one doubts. 
On July i, a lady was referred to me by Dr. 
H. D. Fry, who in a note stated that the lady sup- 
posed a fish bone to be lodged in her throat and 
she claimed the same having remained there since 
—a period of six weeks. She made the same 
statement to me and added that shortly after she 
made attempts to remove the object with her fin- 
ger, but was unsuccessful. The bone continued 
to give her considerable annoyance, especially 2 
during the intervals between meals, causing her 
to make frequent efforts at “empty swallowings.” 
While she could always feel the presence of the 
body yet its position was never such as to cause 
any interference with the act of deglutition, nor 
to any apparent obstructive sensations. She states 
that the swallowing of bread-crust would dimin- 
ish, momentarily, the intensity of her sensations, 
which was no doubt due to the roughness of the 
bread ‘1 scratching ’ ’ the mucous membrane. The 
supposed location, she states, was somewhat lower 
at first than at present. The location of the sen- 
sation frequently changed, at one time being on 
the right, again on the left side and then in the 
middle of the throat. 
Such a history as the above, with regard to the 
change of location in the position of the bone, 
seemed quite unusual for that of a foreign body 
—such bodies, especially if pointed, usually re- 
main fixed in the position they originally take, 
The pharynx and larynx I examined with the 
utmost care, although little expecting, on account 
of symptoms given, to find any trace of the sup- 
posed origin of the trouble. My examination not 
being attended with success, and as the patient 
was unusually tolerant, I determined to make a 
digital examination of her throat. This was also 
unsuccessful. I subjected her to three subsequent 
examinations, all of which were attended with the 
same result. The only deviation from the normal 
noticed in the throat, which arrested my attention 
during the first examination, was a peculiar vascu- 
lar condition of the right base of the tongue. 
This condition I did not at first attach as much 
importance to as upon subsequent examinations 
and more mature consideration. A similar condi- 
tion, attended with exactly an analogous train of 
symptoms, not arising from an analogous cause, 
we have since noted in another patient. The pa- 
thological change which I refer to is the existence 
of a small area of ecchymosis or submucous hem- 3 
orrhage grouped together like a bunch of grapes. 
This area of hemorrhage effusion, or “ spots ” as 
I shall designate them, had the appearance as 
though small red shot had been deposited beneath 
the mucous membrane. The area of effusion va- 
ried from one to one and a half centimeters in 
length and from one-half to three-fourths in 
breadth ; while the individual spots varied from 
one-half to one millimeter in diameter. These 
spots while not being hard yet cause sufficient 
elevation of the mucous membrane to make them 
distinctly discernible to the sense of touch. As I 
have stated above, I noticed this condition during 
my first examination but almost immediately dis- 
missed it from mind as I thought it probably due 
to the irritation caused by the presence of the 
foreign body. During my second examination 
these spots aroused my suspicion and I determined 
to touch them lightly with the probe. On touch- 
ing the spots and requesting the patient to state 
whether I was near the point at which she located 
the sensation, she intimated that I had touched 
the exact point. She then informed me that she 
was now certain that I would be able to remove 
the object inasmuch as I had been so successful 
in going directly to the point where it was located. 
After three days she reported again, her face radi- 
ant, and greeting me with unusual cordiality, she 
stated that she had certainly felt the bone with 
unusual distinctness within the last hour. It had 
changed its position from right to left. On intro- 
ducing my mirror I was somewhat surprised to 
find the same pathological condition manifested 
on the left side that I had previously noted, three 
days before, on the right. A few days later I 
noted a similar condition near the centre of the 
base of the tongue, and with this new focus an 
alteration of the supposed site of the bone to this 
new point. On each subsequent examination we 
noticed that the previously existing spots had di- 
minished somewhat in area as well as distinct- 4 
ness. The effused blood gradually became ab- 
sorbed. 
On July 22 a lady whose daughter had previ- 
ously been under my treatment, presented herself 
for the purpose of having her throat examined. 
Her train of symptoms were as follows : She had 
for several months, at varying intervals, a sensa- 
tion in her throat as though something was lodged 
there which she must remove. This something 
felt scratchy, as she expressed it, very much as 
though there was a small area of roughness in 
her throat. She had had these same peculiar sen- 
sations some eight months before, but they had 
subsided after several weeks’ duration. On differ- 
ent occasions she located the sensation in different 
positions—at one time to the right, again to the 
left, a little higher and then lower. She never 
suffered pain nor was there any obstruction of the 
throat or difficult deglutition. She had previously 
been under treatment. A spray had been placed 
in her hand which she was diligently using upon a 
normal nasal and pharyngeal mucous surface. On 
making a larynxal examination I was very much 
surprised by the great resemblance which this 
case bore to the preceding one ; the whole mucous 
surface of the larynx, pharynx and naso-pharynx, 
excepting that portion covering the base of the 
tongue, had a normal appearance. The base of 
the tongue presented the same pathological change, 
the hemorrhagic effusion, which I had noted in 
the preceding case. Although my experience in 
the preceding case would have justified my con- 
cluding that there was a certain causal relation- 
ship existing between the pathological changes 
present and the symptoms manifested, I was not 
hasty in drawing a conclusion but rather waited 
for further developments. 
Five days later, after an almost complete sub- 
sidence of all symptoms, as well as a diminution 
in size and prominence of the spots, many of the 
smaller ones having completely disappeared, she 5 
had an increase in the intensity of her symptoms, 
and on making an examination a new area of 
hemorrhage was visible, larger and more promi- 
nent, situated three-fourths of a centimeter to 
the right of the former area. I introduced a 
probe, and in order to avoid any possible error, 
told the patient to indicate when I had touched 
the point at which she located her abnormal sen- 
sations. When the probe came in contact with 
the first effusion she stated that there she felt an 
unpleasant sensation, but not until I passed 
gently over the surface of the new effusion did 
she give any evidence of certainty as to location. 
I now could hardly resist the conclusion that 
there was, in this case, a direct causal relation- 
ship existing between the pathological changes 
present and the symptoms manifested. In these 
two cases we have symptoms almost analogous, 
their origin ascribed to different causes, present- 
ing pathological changes wrhich are identical in 
their character. The important question is to 
decide what relationship exists, if any, as re- 
gards cause and effect between the only patho- 
logical change present and the peculiar train of 
symptoms manifested. It is important to decide 
whether the symptoms existing, necessarily 
nervous, gave rise to the pathological changes, 
or whether the pathological changes having been 
produced were the cause of the train of symptoms 
manifested. Supposing the phenomena to be of 
a nervous character, is it possible that the pa- 
tient by repeated and frequent efforts at clearing 
of the throat, rasping and coughing—in the 
effort to remove the supposed foreign body—is 
capable of producing a hemorrhagic effusion in 
this position. Admitting the hemorrhage to be 
produced in the manner mentioned above—no 
pathological change being present—is it possible 
for the seat of the supposed foreign body to 
change from that at which it was formerly lo- 
cated to the seat of the effusion. The hemor- 6 
rhagic effusion gradually undergoing absorption, 
with a subsidence of the symptoms, a re-occur- 
rence of the effusion in a somewhat removed po- 
sition being attended by a re-occurrence of symp- 
toms in their original intensity—supposing no 
pathological change primarily to have been pres- 
ent—is it possible with the full disappearance of 
the effusion that the symptoms will also com- 
pletely subside. In other words, is it possible 
for a purefy nervous phenomenon to attach itself 
to a demonstrable pathological lesion, subside 
with the disappearance of the lesion, recur with 
its re-occurrence, and to disappear entirely with 
the disappearance of the lesion. 
The first and most important interrogation 
to answer, is the one in regard to the possibility 
of the patient, mechanically, producing the 
pathological lesion mentioned. During the effort 
of clearing the throat as well as retching the 
tongue is entirely a passive organ, not sufficient 
muscular force being used to rupture a weak- 
ened arteriole even in a state of congestion ; nor 
do I consider sufficient congestion of the vessels 
of this organ to be produced, during these efforts, 
to produce a rupture of the capillaries at its base. 
We have never before noticed an analogous con- 
dition in any throat, and if seen by others they 
have never attached sufficient importance to it to 
give it a description. It is quite possible that 
the condition may be the same as that known 
as miliary aneurisms of the tongue. Butlin 
states : ‘1 Ecchymosis may occur in or beneath 
the mucous membrane from other causes than 
purpura he goes not farther, and does not men- 
tion the nature of other causes. In the cases 
here mentioned the patients were known not to 
have made any violent efforts, of the kind men- 
tioned, and after coming under my care no efforts 
of this character were made, yet the effusion re- 
occurred several times in both cases. The burden 
of proof rests on the other side. 7 
Admitting the possibility of the second sup- 
position, which could be manifested possibly in 
certain phases of hysteria and melancholia—a 
laryngitis often causing the syphilophobiac to 
suppose that the chancre has re-appeared in his 
throat—we must admit that our patients were 
hysterical or melancholic. Our patients were ro- 
bust women of a decidedly phlegmatic tempera- 
ment, displaying no nervous phenomena of any 
character. They were of 50 and 45 years of age. 
Bven admitting the patients to be of a hyster- 
ical temperament, and the original phenomena to 
be hysterical, followed by the hemorrhagic 
effusion—mechanical in its origin—is it possible 
that the symptoms should disappear with the 
complete disappearance of the only pathological 
lesion manifested. I could hardly conceive of 
such a condition; therefore am rather forced to 
the conclusion that the hemorrhagic effusion was 
the original pathological lesion which gave rise 
to the subsequent symptoms. 
In one case, that of the fish bone, the probable 
irritant was a bone which may or may not have 
found lodgment in the throat. The foreign body, 
if it ever entered the throat, must have been im- 
mediately expelled by the effort of coughing, ex- 
cited by its presence. I am rather inclined to 
believe that no such object ever found lodgment 
in the patient’s throat; the effusion occurred 
about the same time, and she supposed the symp- 
toms produced thereby to be the result of the 
fish bone. We know how unreliable the state- 
ments of patients are in regard to such matters. 
Patients very frequently persist in asserting that 
a foreign body is still lodged in the throat, 
weeks after the occurrence, when its lodgment 
was only momentary. In all cases where foreign 
bodies lie imbedded in the substance of the 
tongue it gives unmistakable evidences of its 
presence. The wound does not heal and it lies in 
the midst of an indolent tumor, the wound lead- 8 
ing down to its surface. I think we must con- 
clude that the fish bone never was present in this 
case ; the eating of fish and the effusion occurring 
simultaneously, the patient immediately ascribes 
the phenomena produced by the effusion, to the 
lodgment of a bone. We can readily conceive 
how such would be the case, as a hemorrhage 
would be almost as sudden in its production—the 
train of symptoms as suddenly produced—as 
those produced by the swallowing of a bone. 
In our second case we have a much simpler 
condition of affairs, and one in which there is 
not the same doubt as to the origin of symptoms. 
Here our patient came to me with a feeling of 
fulness in her throat, and the sensation of a 
foreign body lodged there—resembling very much 
the sensation imparted by a crumb of dry toast. 
These symptoms being greater at one time than 
another, and varying in their location. It seems 
to me that my position, at least in these two 
cases, is proven beyond doubt. We have here a 
pathological lesion, producing a train of symp- 
toms which ameliorate and disappear with a 
diminution of and disappearance of the change ; 
the symptoms to re-occur in their full intensity 
in another locality, with the reappearance of 
pathological changes in another position, the 
symptoms to completely subside with the dis- 
appearance of the lesion. The symptoms are 
somewhat analogous to those produced by en- 
largement of the glands at the base of the tongue, 
and to those arising from a varicose condition of 
the vessel in the same locality. 
I can offer no suggestion as to the etiology or 
pathology of this condition. 
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