CHAPTER XL

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THE MOUTH, THE TONGUE, THE TEETH, AND THE JAWS.

CONGENITAL DEFECTS.

Aside from anomalies due to incomplete closure or erratic development from the branchial clefts, the principal congenital defects of the regions included in this chapter are as follows: The mouth is essentially a coalescence of the upper end of the foregut and a recess known as the stomodeum, which are at first separated by membrane, the latter disappearing early in fetal life. Some remains of it, however, may produce a narrowing of the oral fissure and cause one form of _microstoma_. Some of these facial defects are due to formation of amniotic bands and adhesions, which restrain or interfere with the normal development from the branchial fissures. Malformations of the _tongue_ may accompany other anomalies. A _median cleft_, called also a _bifid tongue_, and defective development and undue adhesions to the floor of the mouth, are known, whose most trifling expression may be seen in the so-called _tongue-tie_, where the frenum is too short and needs to be divided in order to release the tip and more movable part of the organ. Adhesive bands may also attach the tongue laterally to the cheek, bands between the cheek and the gums being also occasionally seen. An extreme type of tongue-tie is known as _ankyloglossum_. Abnormally long tongues are also met, and cause an actual menace from danger of the tip being swallowed, as children have suffocated from this cause. _Congenital macroglossia_ has been described; it is usually due to lymphangioma of the tongue. A condition known as _lingua plicata_ is characterized by moderate enlargement of a number of either longitudinal or transverse folds or rugæ. The covering mucosa, however, is normal. _Complete absence of the tongue has been noted._

Aside from malformation of the upper jaw, _cleft palate_, there are arrest of development in one or both sides of either jaw and a failure of union in the two halves of the lower jaw. Anomalies about the temporomaxillary joint interfere with its function and may prevent separation of the jaws.

_Malformation and misplacement of the teeth_ are extremely common. Thus a tooth may develop in an abnormal position by displacement of its body, or it may project in an abnormal direction; while teeth may be lacking in number or in eruption, so that a given tooth, usually a molar, completely fails to appear. Absence of a number of teeth is more rarely noted. Numerous cases are on record where a third set of teeth has succeeded the second instead of the latter remaining permanent. Abnormalities of tooth formation extending to the dignity of tumors of the dental tissues have been referred to in the chapter on Tumors, under the head of _Odontomas_. Cysts of congenital origin not infrequently develop around unerupted or misplaced teeth, and constitute tumors which at birth are scarcely noted and which may not develop until later in life.

Persistent remains of the _thyroglossal or thyrolingual ducts_ may be seen early in childhood, or not until late in life. Their consequence is occasionally noted in the existence of _fistulas_, but more often of _cysts_ or _dermoid tumors_, which, though having their origin in the middle line, may become displaced to one side, and when seen by the surgeon have a lateral position.

CLEFT PALATE.

Cleft palate is a congenital defect due to failure of coalescence between the nasal and maxillary processes, which, proceeding from either side, should meet and unite in the middle line. The defect may be so slight as to produce only a small notch in the alveolar border, or a small opening in the roof of the mouth, or it may be so complete as to constitute a separation with the formation of but a small part of the roof of the mouth, leaving but little tissue serviceable for any possible operation. The relation between the products of lateral growth and the downward projection and formation of the _intermaxillary bone_ by the midfrontal and nasofrontal processes is too complex to be described here (Fig. 465). In some instances there is but little evidence of the formation of such a bone, while at other times it has not only bone formation but is relatively overdeveloped, in such a way as to make the lower anterior angle of the septum and its own part of the alveolar process project far beyond the level of the surrounding tissues, thus producing a snout-like appearance, which not only makes the case more disfiguring, but seriously complicates operative procedure. Usually the lower border of the nasal septum will be found attached to one side of the cleft (Fig. 466). The soft palate presents the same fissure, and the uvula is often neatly separated into halves.

[Illustration: FIG. 465

Double cleft palate.]

[Illustration: FIG. 466

Left-sided cleft palate.]

The _coincidence of cleft palate with hare-lip_ has been described. (See p. 645.) While they often are combined, either may occur without the other (Fig. 467).

[Illustration: FIG. 467

Left-sided hare-lip and cleft palate. Marked displacement of intermaxillary bone. Boy, aged six years. (Bevan.)]

No matter how incomplete the palatal cleft may be the nose and the mouth are converted into a common cavity. Suction, as from the breast, is impossible. Infants with this defect should be carefully fed by hand; as they develop, food passes readily from the mouth to the nose, while there is corresponding difficulty in swallowing. With lapse of time speech becomes defective or almost unintelligible. There is, therefore, every reason for any possible closure of such defects. Against the mechanical difficulties on one side should be weighed the desirability of such closure on the other. One argument advanced in favor of operation on hare-lip is that the influence of the pressure thus afforded will tend to hasten the natural attempt on the part of the halves of the upper jaw to grow toward each other instead of in the opposite direction. On the other hand, by closure of the labial defect, the space within is materially diminished and manipulation made more difficult. It then becomes a serious problem _when to operate upon a given case of cleft palate_. The operation itself is usually one of no small mechanical difficulty, the space required for manipulation is most restricted, the procedure relatively a long one because of the anesthetic, and necessity for its frequent suspension in order that the operator may proceed, and, because of these difficulties and delays, the attendant shock to the patient. A puny child, unable because of the defect to take sufficient nourishment, is then in far from a favorable condition for a serious operation. Without a general anesthetic no child will endure it, while local anesthesia in the young is insufficient on account of their timidity and involuntary resistance. When to operate, then, should depend upon the condition of the child, the dexterity of the operator, and the width of the cleft--that is, the amount of work to be done.

Brophy, of Chicago, has taken a radical and advanced position in this matter, and believes that these operations should be performed in early infancy, a fact which his own large experience would appear to demonstrate. Yet this same experience has developed in him a facility possessed by few, and that which such an operator may do with impunity can be duplicated by but few. He finds, however, unanswerable argument in this: that in infancy the bones of the jaws are scarcely developed, are not only friable but very flexible and yielding; that even in the very young the tissues unite kindly, and that very young infants seem to be less liable to extreme shock than those several months old; that the earlier the muscles of the palate are brought into contact and action the better performed are the functions of deglutition and of speech, and that if they are not used they atrophy; that the teeth are more likely to erupt normally, and that the extreme liability to pharyngitis produced by such wide-open fissure is obviated. To all of these statements no objection can be raised, and the only argument which can be adduced against Brophy’s position is the actual danger of the operation.

In the matter of time it may be said that in extremely competent hands operation in infancy is the ideal method, but that when children reach the age of two or three years and still have very small mouths, not much is lost by waiting until they are five or six years of age, while considerable room is gained for ease of manipulation. Much depends also on the temperament and obedience of the child. These children, like most of those born with congenital defects, are usually pampered and spoiled by indulgent parents, so that at a time when implicit obedience is most needed it seems almost impossible to do anything with them. In dealing, therefore, with such a child one should insist upon its being thoroughly disciplined, and, at the same time, accustomed to manipulation within the mouth, as the presence of a finger, tongue depressor, etc., so that when need comes for their use the child shall not be totally unaccustomed thereto. Every case should also be prepared so far as possible by antiseptic and astringent mouth-washes. A nasopharyngeal catarrh which shall compel such a patient to be constantly swallowing and spitting may defeat the object of the operation itself.

The terms usually used in this connection are _uranoplasty_, which means closure of the hard palate, and _staphylorrhaphy_, which means the closure of the soft palate.

=Operations for cleft Palate.=--The responsibility of the anesthetist in these cases is great. Considering that he has to work through the same cavity as the surgeon it is sometimes very difficult to keep the child in a consistent state of narcosis. The inhaler devised by Dr. Souchon serves an admirable purpose. (See p. 644.) I regard chloroform as the safest of the anesthetics, as it is less irritating and provokes less flow of saliva. It is a good plan to cocainize the parts previous to incision, in order to so benumb them as to make reflex impressions less pronounced.

The theory of these operations, like that for hare-lip, is simple. It consists in freshening the edges of the cleft, bringing them together and holding them in position; this requires clean work and a mouth kept clean--in other words, it calls for efficient antisepsis, for strict asepsis is impossible. All carious teeth should be removed or put in good condition, and large tonsils, with their distended crypts and reservoirs of decomposing material, and all adenoid tissue should be removed.

Owen has shown the benefit in nursing infants of using an old-fashioned “slipper bottle,” having a soft giant teat with a hole on the under surface. As the infant sucks from this the teat fills the cleft, and as the child compresses it in sucking the milk is directed downward. When this does not suffice milk may be given in a warm teaspoon, passed far back over the tongue, or from a medicine dropper.

Owen sustains Brophy in the contention that the most favorable time for operating on a cleft palate is between the age of two weeks and three months, there being at that time less shock, and the bones are extremely flexible. Accepting this statement as authoritative the operation upon young infants will be described.

Previous to the operation a warm, nourishing, and stimulating enema should be given the patient. After the infant is anesthetized the tongue is drawn forward by a long suture and the mouth kept open by a mouth-gag. The edges of the cleft are then pared with a sharp knife, after which effort should be made to press the upper maxillæ together, in order to test their flexibility and the possibility of approximating them in this manner. This will rarely be sufficient, however, and it becomes necessary to raise the cheek, on each side, toward the posterior extremity of the hard palate just behind the malar process, and pass a knife through the outer bony surface, making a sufficient division of the antral wall through a minimum of opening. Rather than cut too much bone at first the knife may be re-introduced. The actual approximation of the maxillæ is produced by silver-wire sutures. A firm, stout needle carrying a thick, silk pilot suture is passed through at the point above mentioned and made to appear in the fissure, where the loop may be pulled down, after which it may be again passed through the other side and made to emerge at a point corresponding to that at which it entered. The suture thus passed in one way or the other is made to carry a strong silver wire from one side across to the other, on a level above the hard palate, emerging on each side within the cheeks. Another wire suture is similarly passed more anteriorly. Two small oblong leaden plates, 1.5 Cm. in length and 35 or 40 Cm. in width, drilled with two holes, are then provided, one of them laid along the outside of each maxilla, the wire sutures passing through the holes which they contain. On one side the ends of the wire are then twisted firmly and cut short, thus forming a complete grip upon the plate on its side; then the jaws are pressed firmly together, while the wire sutures on the other side are similarly fastened over the lead plates and twisted tightly to make permanent the effect produced by pressure with the fingers. These sutures should be made sufficiently tight to permit of approximation of the borders of the mucoperiosteal surfaces, already freshened, in such a way that they may be held together with fine wire or horse-hair sutures and without undue tension.

The lead plates are left _in situ_ for three or four weeks. If necessary the wire suture may be tightened to allow for relaxation produced by pressure effect. Some ulceration may occur beneath the plates, but this heals after their removal. Theoretical objection to this method may be made because of the tendency to narrowing of the upper jaw. In fact, however, it is only restored to its proper dimensions, as that part of the face has been previously widened by the width of the cleft. Irregular eruption of teeth or irregularity of development may be treated by a dentist.

When the vomer affixed to the intermaxillary bone projects in a snout-like manner it is necessary to remove a V-shaped section from it, the base of the triangle being along the margin of the cleft, in order that the projection may drop backward and the corresponding part fall into line with the rest of the alveolar process. This is best done as a preliminary and distinct operation.

_Uranoplasty in older patients_ consists essentially of forming two anteroposterior mucoperiosteal flaps, from the hard and soft palates, on either side of the cleft, with their inner edges neatly pared, which should be separated from the bony roof of the mouth, and slid toward each other until they can be held together by sutures. These operations are best performed with the patient’s head hanging over the end of a table, so that blood may not find its way into the trachea or stomach, but be sponged away. This is the position of the so-called “down-hanging head” described by Rose. In fat-necked individuals it may be impracticable. After paring the borders adjoining the fissure an incision is made just within the alveolar border, close up to the teeth, parallel to the former, of sufficient length to permit of the formation of the flap above mentioned; then with raspatories or elevators it is detached from the hard palate. In a mouth with a gothic arch or roof it is often easier to form these flaps and to bring them together than in others. It may be possible in such cases to not only suture the edges, but also some portion of their raw surfaces, thus ensuring better union. (See Fig. 468.)

Branches of the anterior palatine artery will bleed freely during this part of the performance. Firm pressure and the use locally of adrenalin solution will usually overcome this difficulty. As the incision is extended backward the posterior arteries will cause the same difficulty. The wider the defect the farther backward should the lateral incisions be extended. Here the principal obstacle to easy approximation of edges is the activity of the levator and tensor palati muscles. Formerly it was a part of operations to divide the tendon of the latter as it passes around the hamular process. It has been found, however, that this is often unnecessary. A tenotomy of this tendon, however, may be made just as that of any other tendon with the expectation that the gap thus made will be filled with fibrous tissue. While, on one hand, it is of great advantage to spare this tendon, on the other hand its muscle may be the principal factor operating to pull apart those surfaces which have been neatly brought together.

Fergusson and Langenbeck have not hesitated to make _osteoplastic flaps_ when necessary, dividing the hard palate along the line of the lateral incisions with a fine chisel. This is not often required, and complicates the case to an undesirable extent, although it may be necessary in wide fissures with a minimum of tissue (Fig. 469).

Sutures are best made of fine silver wire or of black silk, as the ordinary silk is usually too absorbent, and permits infection of the stitch holes. These sutures are introduced with any one of a variety of needles devised for the purpose. A complicated needle is not necessary for this purpose, for with an adequate needle holder even the ordinary needles can be used. Silver wire may be fed directly into the needle or through a hollow needle devised for the purpose, or sutures of silk may be passed, by which a wire suture is pulled after them.

Great assistance can be obtained from packing strips of gauze between the flaps and the bone from which they have been detached. These may be inserted for pressure effect and prevention of hemorrhage during the operation, and later may be substituted by smaller packing of antiseptic gauze left for the purpose of helping to minimize tension, flaps being crowded toward each other by their use.

[Illustration: FIG. 468

Uranoplasty, showing incisions. (Tillmanns).]

[Illustration: FIG. 469

Staphylorrhaphy, sutures placed. (König.)]

The parts being approximated and the wound suitably tamponed it is necessary to keep the patient as quiet as possible. Young infants tend to keep up a constant sucking motion with the tongue, which may interfere with the quietude of the palate. Small doses of bromide or chloral may be administered either by the mouth or rectum, for every effort at crying, coughing, or vomiting tends to make a stress upon the line of sutures. Vomiting immediately after the operation is not necessarily serious, and yet should be avoided. Patients sufficiently old to talk should be cautioned not to converse. Water is better for the patient than milk, as the latter does not allay thirst so well and may form curds. Most of the nourishment for the next few days should be administered by the rectum, giving only water through the mouth. Children should be watched continuously lest they get fingers or toys into their mouths, and fretfulness should be guarded against. Thread sutures should only be removed with scissors and forceps after the expiration of five or six days. A useless suture is a foreign body which does more harm than good. When lead plates are used with strong wire sutures they should remain from two to four weeks. In young or undisciplined children it may be necessary to give an anesthetic for removal of the sutures. The tampons or pledgets of gauze should be removed from day to day. An antiseptic mouth-wash or spray should be frequently used.

The two results most desired are prevention of passage of food from the mouth to the nose, which is always commensurate with the success of the operation itself, and improvement in speech and voice. The earlier the closure the more natural the voice. Patients in adolescence or adult life rarely note much gain in this respect, while those operated in early childhood may learn to talk almost perfectly.

There are cases, especially those which have gone for years unattended, where the arch of the mouth is of such gothic shape and the defect so wide that disappointment is sure to follow in at least one of the above respects. The art of the dentist has now reached a point where plates or obturators may be constructed for unsuitable cases, which will give better functional and vocal results than any which the surgeon can produce.

Another form of palatal defect is the result of the late manifestations of _syphilis_, and small and large perforations may occur, usually in the hard rather than in the soft palate. They are to be dealt with surgically, but not until after the patient has been subjected to a course of antisyphilitic treatment.

THE MOUTH IN GENERAL.

The mouth more than any other part of the body is the habitat of a large fauna and flora of minute organisms. Over one hundred different kinds of bacteria from this region have been identified by Miller, and it will be easily seen how prone fresh wounds or old lesions may be to infection from these sources. Fortunately but few of these microörganisms have decided pathogenic propensities. They lurk especially in two localities--the crypts of the tonsils and along the gingival borders and alveolar processes. Along the gingival border of the teeth _tartar_ accumulates, by a precipitation of mineral salts from the saliva, where by irritation, coupled with germ activity, the gum is loosened from the teeth beyond the level of the enamel, and the sockets thus exposed to various kinds of infection. In consequence the teeth thus undergo _dental caries_, become loosened in their sockets, while, at the same time, infection travels along lymph paths until the germs are filtered out in the adjoining cervical lymph nodes, which thus suffer enlargement and often suppurative destruction. An _interstitial gingivitis_, therefore, is always a serious menace to the integrity of the teeth. This will furnish another argument for a semi-annual inspection of the mouth by a competent dentist, that he may clean away all tartar accumulations and treat the gums in such a way as to prevent disintegration. In elderly people, especially, there is a marked tendency toward _retrocession of the gums_. In young or old, when this condition is noted, it may be treated by applications of zinc iodide, either of the dry, minute crystals or of a saturated solution, which may be used daily or weekly. By such precautions the teeth may be preserved to old age, the importance of which is not generally appreciated, since the teeth are necessary for suitable mastication of food which the enfeebled stomach of an aged person can more easily digest.

Infection may also occur during the period of eruption of teeth in young people, and serious trouble sometimes accompanies the appearance of temporary or permanent teeth. Gingivitis of toxic origin is not uncommon, as among the possible effects of overdosage of _mercury_ and _phosphorus_.

All that has been said of the teeth and their sockets is in the main true of the tonsils, which afford numerous crypts or lacunæ in which germs may be harbored for a long time. The explanation of probably 75 per cent. of enlarged and tuberculous lymph nodes is afforded by infection spreading from the tonsils and teeth. It may not be tuberculous at first, but it becomes so later.

In the mouth may be seen expressions of _actinomycosis_, _tuberculosis_, and especially of _syphilis_, among the more chronic lesions, as well as of diphtheria, erysipelas, and the result of the _oidium albicans_ of _thrush_. Tuberculosis is more common in the pharynx, while the syphilitic infections may appear anywhere and in any form, as chancre on the tonsil or the lip, mucous patches of the tongue, destructive lesions of bone, all of the earlier and most of the later expressions of the disease offering serious dangers of contagion.

_Stomatitis_ is a term generally applied to the lining membrane of the mouth and indicates little regarding its nature or seriousness. It may be of traumatic origin, as when strong caustics have come in contact with the mucosa. _Ulcerative stomatitis_ is a disease of childhood, due to the activity of the _oidium albicans_ or some kindred microörganism, it being usually a more serious expression of the condition known as “thrush.” Washing the mouth frequently with dilute solutions of hydrogen peroxide or of tincture of iodine will usually be all that is necessary. Resistant ulcerations may be treated with 10 per cent. solution of silver nitrate. _Stomatitis gangrænosa_ is another name for _noma_, or _cancrum oris_, which was described in the chapter on Gangrene. In these cases the surgeon should hasten the tedious separation of sloughs by use of scissors, curette, or the actual cautery (Fig. 471).

_Blastomycetic lesions_ of the mouth, and especially of the lips, have been recognized. Bevan has reported extirpation of granulomas provoked by the blastomycetes, or yeast fungi, which are known to produce similar effects elsewhere (Fig. 471).

[Illustration: FIG. 470

Misplaced and imprisoned tooth. (Forget.)]

[Illustration: FIG. 471

Destruction of cheek the result of cancrum oris. (Tiffany.)]

Severe infections of the mouth may also involve the tongue and thus produce acute glossitis or may spread to the connective tissue, or the submaxillary region, and there produce that type of phlegmon called _Ludwig’s angina_, described in the chapter on the Neck. The source of infection in most of these cases is a tooth or tooth-socket.

_Injuries and wounds of the mouth_ are _liable to septic infection_, whether they occur from mechanical, chemical, or traumatic causes. Injuries inflicted by the mouth, or rather by the teeth, _upon others_ constitute infected wounds of a serious type. Burns, scalds, and similar lesions inflicted by violent caustics, such as carbolic or nitric acids, may be followed by cicatricial contraction and produce serious consequences. So far as the latter can be foreseen they should be prevented, while for their more extreme results various plastic operations may be performed.

THE TONGUE.

What has been said above with regard to the possibility of infected wounds in the mouth applies also to the _tongue and other parts_. It is often lacerated by being caught between the teeth in falls and blows and is sometimes bitten by epileptic patients during their convulsions. Free hemorrhage from such wounds may occur and may require ligation of vessels at the site of the wound, or of suture of tissues _en masse_ with catgut, or ligation of the lingual artery just above the hyoid bone. Lacerated wounds should be closed with sutures, and antiseptic mouth-washes should be frequently used.

_Glossitis_, or inflammation of the structures of the tongue, may appear in either acute or more chronic form. To some extent it is a part of a general stomatitis, but no matter in what form occurring it is an expression of infection from a source easily recognized, and may be limited to one side of the tongue. Its principal features are swelling, which may be so extensive as to prevent movement of the tongue, infiltration of the floor of the mouth, and extension of a phlegmonous type down the structures of the neck. The swelling may also involve the epiglottis and larynx, causing edema and even suffocation unless tracheotomy be performed. Thus acute glossitis may frequently lead to _abscess_ formation either in the tongue or the adjoining tissues. When swelling is extreme its formation may be anticipated, and free incision should be promptly made to permit of its evacuation. Naturally the region of the large vessels should be avoided, and, after external incision the focus should be reached by blunt dissection. Some of these cases are due to extension of an erysipelatous process commencing externally. Even _hemiglossitis_ may be accompanied by serious swelling and high fever. One form of this affection is supposed to be analogous to herpes zoster. The relation of phlegmonous glossitis to _Ludwig’s angina_, the latter being described in