What we have here is a classic ulcer. The body exposes itself, becoming raw flesh, in such a place to make you keep touching it, and by touching it hurting it, and by hurting it hurting you because you’re your body (of course). This – or really, you – makes you, helpfully, aware that something is wrong. And, as you can see, there is an ulcer right on the tip of this patient’s tongue. It is really like her tongue has no tip at all, and rather the wide muscle, usually so pliant and receptive, lying placidly in her mouth, has been subsumed by pain. 

Now the patient must be permanently aware, even with her tongue safely behind her teeth, that the slightest attempt at speech will mean moving the whole machinery of the mouth. Even taking the greatest care, this will result in her allowing something to touch the tip of her tongue which must hurt her. As we’ve seen, she is unable to eat much, or sleep well, or brush her teeth, or tell us what we need to know. We’ve often observed that even momentary pain of such a kind is usually enough to prevent action, even in hardier patients. And speaking in this case would probably cause her such pain that if she then continued, we would be forced to conclude that she is unreasonable. She would obviously be the kind of person unable to learn from their mistakes and must be treated as such.

If ulcers had been studied at the right time, perhaps we might have ulcerological maps in the way we had phrenological ones. And it would have been a very handy science indeed, if it existed, in the same way phrenology was useful when it was true, although we would never believe such a thing now, of course. Because the bruises we can see on the patient’s arms and legs can only tell us that her body is already healing itself (without our help) from the damage inflicted by whatever hurt her in and around that particular place. Don’t hit yourself and you won’t bruise. It is quite simple. However, the inner cause of her non-healing ulcer, the kind of stress making itself manifest, is unknown to us. Perhaps ulcerologists, as they would have been called, would have had little models of ceramic mouths with detachable tongues, divided by clear black lines, and a doctor could point to what was wrong from where it was wrong. If it was, say, money worries, maybe the ulcer would be located in the back of the mouth. People would say: ulcer of the inner lower lip? Unlucky in love.

I should think that in a case like this, the patient’s condition could be diagnosed as the result of her selective mutism. It would make sense, hypothetically, if we accepted everything else, that an ulcer affecting the speech is caused by speech-related stress. The tongue-tip ulcer would thus emerge to helpfully make the stress of this condition known to her doctors by enhancing its symptoms and enforcing a previously voluntary silence.

Although it has been a few weeks, we are certain that the ulcer will go away soon, much like the bruises. Not necessarily cured, but certainly abated—which is the best the patient can hope for with such a virulent case. The ulcer will have given the patient plenty of time to think of the words she really needs to say. It will have fulfilled its purpose when it forces her to break her silence, for the right reasons, after a few more days, a week at the very most. When she speaks, as she surely must do soon, and confirms my hypothesis, it will be a triumph for ulcerology. Or it would be, if it only existed.

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