The Coated Tongue - Its Cause And Meaning
( Originally Published Early 1925 )
The coated tongue is due to the blood being charged with toxins. The tongue's resistance and that of other fluids is thus lowered, the saliva loses its power to stop the growth of micro-organisms and the mouth becomes an incubating chamber in which molds and bacteria of various sorts grow luxuriantly. In this condition the colon should be cleansed up to the cecum by coloclyster (high enema) once or twice daily. Five minutes should be consumed in allowing the colon to fill in the knee-chest position (the chest lower than the hips) and the last enema should be at 80°'
Boas says uncleanliness of the tongue is often the cause of bitter taste and bad odor. By scraping off the "fur" (bacteria, mucus, molds, deposits from the stomach or intestine and horny growth on the tongue) with a cotton swab or spatula one may frequently convince one's self of the source of the bad odor.'
Wainwright thinks the tongue may be a good index of intestinal health, and a foul condition of the breath speaks volumes of what may be suspected lower down, although in the ordinary sense the patient may not be constipated.' In such cases, says Kellogg, the constipation is latent. A barium meal will show ileum stasis of a most pronounced degree (delay in the ileum, small intestine) , most often in the last twelve inches. When the tongue is thickly coated the breath has a bad odor and not infrequently a characteristic fecal odor. In such cases there will always be found very pronounced intestinal stasis, the food residues and other body wastes being retained in the colon to putrefy instead of being promptly dismissed.
Such chronic conditions indicate, along with constipation, a defective ileo-cecal valve and an inefflcient intestinal flora (microscopic plant life). With the stasis and flora corrected the defective valve will not need attention. Even if such a valve were mended by a surgical operation and the condition that caused it allowed to remain, the former defect in the valve would recur.
Dickenson remarks on the small amount of good medical literature in existence on this subject; that while every physician from the time of Hippocrates has habitually looked at the tongue of patients, it was done apart from any consideration of theory as to cause and effect. His own theory is that the tongue is an index of constitutional states, seldom of individual diseases. It seldom points to solitary organs or isolated disorders, but is rather a gauge of the effects of disease upon the system than an indication of the locality of it. It is often a guide in treatment so far as treatment is general not local; and it is an important help in prognosis (conclusion as to the course of the disease) . From the standpoint of the doctor it always speaks the truth and a language that is not foreign to the experienced physician. And how much truth is to be read on so small a page! Conditions of fever and of feeding; states of the nervous system; the maintenance or abeyance of vital secretions; failure of vitality al-though we may not be able to find out why; in one case that the patient is improving, in another that he is wasting—all these are discernible to the naked eye.
The two health factors which stand before all others as indicated by the tongue, are the heat of the body and the secretion of saliva. There is a remarkable correspondence between the heat of the body and the coating on the tongue. If the tongue is coated the indication is usually of fever without necessarily special reference to the stomach or liver, and points more to the general system than to the alimentary. The dryness, furring and incrustation are connected with the dearth of saliva, which is an indication always of importance. It is difficult not to infer that with the failure of the salivary glands to function there are other glandular failures, more especially of the digestive system. The speaker had often taken the dry tongue as an indication for peptonized food (predigested). On this subject, however, he had not reached a final conclusion. When the tongue becomes dry and bare, from lack of saliva, it is ill with the patient. He is not sure to die but likely to. The completely bare, red, raw and dry tongue is comparatively rare. The term denuded relates to the completeness of the loss of epithelium (the surface tissue) in certain places, not to its spread over the whole tongue. The indication of the red, smooth tongue is for tonics, stimulants and food, probably liquid but nourishing. The failing pulse does not more surely tell of weakness than, as a rule, does the dry, red and polished tongue. A glance may suffice to show whether it is on the road towards health or from it. When the tongue is approaching the condition of health, so, as a rule, is the patient, as is seen whenever the red, dry and bare tongue acquires moisture and clothing. In fevers the gradual recovery by the tongue of moisture and the exposure of a normal surface at the tip and edges, as the coat recedes, are favorable indications of the greatest significance. There is no better sign in diabetes than the resumption of the natural moisture by a tongue which has been dry. Something may be judged by the way an encrusted tongue cleans; if gradually and from the edges, well; less so when it scales, especially when the surface exposed is red and dry.'
One glance at a coated or plastered tongue may give an assurance which perhaps could not be otherwise obtained, that the disease is on the wane. If the thick coat in the center steeply shelves towards the sides and front, revealing a normal moist, not over-injected surface, the tongue is in process of cleaning; the natural friction is overcoming the coating process, and tongue and patient are on the mend. A tongue acquires a coat more evenly and generally than it parts with it. We can thus tell whether the coating is on the advance or decline and apply this rule to the disease' The dry tongue as an evil omen has long been recognized. Hippocrates 2 more than once refers to it. The speaker's cases, without any special selection, show with the dry tongue, be its origin what it may, a startling mortality, one of almost exactly 50 per cent—56 out of 113. Excess of urine in diabetes mellitus (secondary diabetes) is a cause of extreme dryness of the tongue. Out of 113 cases there were eight of this disease.
The last stage which may succeed the furred tongue or ensue independently, is where the papilla 3 are concealed by an incrustation, usually dark and dry by which the surface is overlaid. From this, the climax of addition, the scale descends through the process of subtraction. With some persons a coated tongue is habitual and not only consistent with health but a sign of it. On the other hand diseases like pneumonia, in which commonly the tongue is quickly and thickly coated, may fail to produce this result. There are peculiarities of the health which concern the saliva. An old woman displayed under capillary bronchitis (inflammation of the smaller tubes) a red, dry tongue (not coated), from which I was disposed to augur ill. She got well and the tongue remained the same. She assured me she had always been so, and I could only infer a want of saliva.'
Microscopic examination of the coated tongue shows the papilla (of the surface) are prominent. There is scarcely an acute or sub-acute disorder at some period of which the tongue is not coated. Want of wear must have some effect in producing this elongation of these papilla. Not only are the tips, to which the wear only applies, elongated, but so in many cases are the deeper parts of the column which are unexposed. Coating therefore is the result in part of disuse, want of rubbing and washing but chiefly of morbid overgrowth. Cases requiring a restriction to a liquid diet are seen daily. The physician is guided chiefly by the presence of fever and the state of the tongue; the more coated the tongue the more liquid the diet. If the tongue be dry the diet is wholly liquid and alcohol a part of it. As the acute disease abates the tongue cleans. Solids are then added and may help the process, but the cleaning comes first. The influence of food and mastication can be considered as no more than of secondary importance'
As to constipation some forms of it or disease associated with it are undoubtedly connected with changes in the tongue. It is not difficult to cite cases where the tongue has remained natural under long constipation either functional or connected with chronic obstruction. On the other hand where the obstruction is acute, the tongue early becomes stippled or coated and dry. The determining factor seems to be the presence or absence of constitutional disturbance which is often not present with simple constipation, or chronic obstruction where the tongue is natural.
Kast gave lycopodium powder in sealed capsules to a number of persons and was able to recover the typical spores of the powder in the mouths of most of them the next morning.
Alvarez has confirmed these experiments. He cites the fact that Grutzner, Sweieznski, Reach and Hemmeter, all German experimenters, have shown in animals and in man that lycopodium spores, or other finely divided and easily recognizable material, given in enemas, will travel in a few hours from the rectum to the stomach. Uffenheimer and Dieterlen, also German investigators, have found that bacillus prodigiosus injected into the rectum could be recovered from the pharynx (in the throat) a few hours afterwards. Alvarez has observed that long before fecal vomiting a brown coating appeared on the patient's tongue with a typical fecal odor. Hence, he thinks it probable that many coated tongues are due to the regurgitation of gastric and intestinal contents, especially during the night. This view, he thinks, is strengthened by the fact that the coating is often heaviest at those times when belching, regurgitation and the feeling of biliousness are most pronounced. He also thinks it probable that the odor of bad breaths comes from actual intestinal material deposited on the back of the tongue, although he does not attribute all coated tongues to such reverse currents. There are other factors, such as the nose, mouth, teeth, pharynx and salivary glands, which must be studied in individual cases. Alvarez gives an instructive instance of a constipated infant who regurgitated so much that her pillow was always wet. After a few weeks her bowels suddenly became a little loose, and the day on which this occurred the mother was surprised to find the pillow perfectly dry. It remained that way for over a week until the bowels became again obstructed. Apparently the establishment of a good current downward instantly stopped all regurgitation upward.
The presence of much bile in vomitus is frequently mistaken by physicians as the cause of the emesis (vomiting). Our author rejects this theory and quotes six German experimenters who by surgical operations on lower animals caused all the secretions of the liver and pancreas to pass through the stomach and there was no vomiting. Hence Alvarez was of the opinion that the presence of bile-stained fluids in the stomach which had been emptied a few minutes before can be taken as regurgitation from the bowel, and that the back flow and the vomiting have the same cause.
He also rejects the view that heartburn indicates a state of acidity of the stomach, quoting E. Schutz, a German authority, J. D. Steele and G. G. Stockton, American authorities, in support of his opinion. The true theory, he thinks, is that expressed by Reichmann, a German authority, who had people swallow a little gelatin-coated sponge on the end of a string. After leaving it for ten minutes in the lower esophagus (just above the stomach) it was pulled out and relieved of its contents by squeezing, when it was found that the liquid was acid in persons who had heartburn and alkaline in normal controls. He concluded therefore that heartburn was due to the regurgitation (expulsion upwards) of the gastric juice (of the stomach).
As to the cause of the acidity in heartburn Fothergill says that it is generally caused by the decomposition of some fat in the stomach, of which there is an excess in the food, with the formation of a fatty acid like butyric acid. In the escape of gas from the stomach, the esophagus being very sensitive, the acrid fatty acid sets up a condition known as heartburn or cardialgia. Of old a favorite cure was sour buttermilk. Such an acid as lactic (butter-milk) or of citric (lemon and orange), which kills the feebler irritant fatty acid, is better for heartburn than an alkali like soda, which forms with butyric acid a butyrate of soda, scarcely less irritant than free acid?. (An additional fact is that where there is a deficiency of hydrochloric acid in the gastric juice, which is frequently the case, soda is contraindicated, as neutralizing the little acid there is.)
How regurgitation can be caused is made plain by Bernheim who says that during a treatment of a woman for floating kidney, nervousness and general debility he administered enemas of cottonseed oil. About five hours after the injection the patient vomited cotton seed oil. These enemas were administered for over two weeks and this was the only time when there was a backflow of oil to the stomach. Bernheim afterwards experimented with another human subject and found that four minute particles of tin foil used in an enema were recovered from the stomach by the instrumentality of a stomach tube. Altogether he made 7 experiments on a man, 7 on a dog and 6 on a woman patient, a total of 20. Of these, 3 made with oil and 10 made with a table salt solution proved successful; 4 with the latter solution proved negative as far as the stomach was concerned, while 3 made with distilled water were also negative, (13 successful 7 negative).
Biliousness, according to Alvarez, derives its name probably from the fact that patients note bile in the regurgitated or vomited material. As presence of bile in the stomach is normal, any excess need not indicate liver trouble so much as an increase in the normal backflow from the `duodenum (upper end of the small intestine). The relief these people derive from purgation, particularly by calomel, is due not to any action on the liver (for all pharmacologists are agreed there is no such action) but probably to a restoration of the downward cur-rent. The relief comes so promptly that Alvarez is sure it cannot be due to the removal of a source of toxins.
In the matter of reverse peristalsis (reversal of the ordinary downward movement of the intestine) Alvarez cites a homely incident that has such universal application that we summarized it. Two boys ate heartily of blackberries at dinner. The next morning A had diarrhea but B seemed all right. Early in the afternoon B began to complain of dizziness, a queer feeling of pressure in pharynx (a part of the swallowing apparatus) and re-current waves of nausea, which came every 20 or 30 minutes). Once or twice he retched unsuccessfully. At supper he made several attempts to eat but each time said the food would not go down. He then felt like defecating and with the help of an enema passed a hard plug. Following this he had a large soft movement containing the remains of the blackberries, and immediately after he asked for food. This child appeared to have had a series of reverse waves which arose in a colon distended by irritant material. These waves took the form of surges of nausea and dizziness with a tension in the throat and an inability to take more food. If the lower bowel had not been emptied when it was B would probably have vomited large amounts of intestinal fluid the next day and a few days later the material might have be-come fecal in character.
Alvarez says he has talked with a number of intelligent persons who objected to nourishment by means of nutrient enemas because they did not like its bitter taste afterwards. He credits Dr. Emge, of San Francisco, with the statement that after severe pelvic operations (in the lower abdomen) it is his practice to give enemas of coffee which can later be detected in vomited material. At first he thought it was dark blood but chemical examination disclosed that it was coffee.