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than a perfectly straight incision, but the resulting scar is rather more
marked. The more perfectly the mucous membrane can be
preserved upon the under side of the lip the better will be the result.

Fig. 456 Fig. 457

The operation for double hare-lip. Operation for double hare-lip: the
sutures in position.

Hare-lip pins have been abandoned. Sutures only are used, which
may be of thread or horse-hair, catgut absorbing too rapidly. It is my
custom to pass a retaining suture of stout silk through the cheek on
either side, at a distance of one inch or so from the wound margin, to
bring this forward in front of the alveolar process, and, by using a
plate and shot on either end, to prevent tension upon the line of
junction. This is very important, for children will fret and cry in a
manner to tear out many a stitch not thus fortified. After operation
young children should be snugly enclosed in a protective bandage
around the chest, by which it shall be made impossible for them to
get their hands to their mouths. It is vitally necessary to maintain
absolute rest of the face and protection from any possible source of
harm.
 Fig. 458 Fig. 459

Line of incision, according to König.

Fissures of the lower lip are surgical curiosities. Should one be

met it may be treated on the same general principles.

Fig. 460

Cheiloplastic operation on lower lip. (Tillmanns.)

The other cheiloplastic operations upon the lips are those made
necessary by excisions of malignant growths, or by deforming
cicatrices such as follow burns, syphilitic lesions, and the like.
 Fig. 461 Fig. 462

Estlander’s cheiloplastic operation.

Fig. 460 illustrates one method of filling a defect of the lower lip,
while Figs. 461 and 462 indicate a method of bringing down a flap
from the upper lip for the same purpose.

THE SALIVARY APPARATUS.

FOREIGN BODIES IN THE SALIVARY DUCTS.

Foreign bodies occasionally enter the salivary ducts, especially
Stenson’s and Wharton’s, where they may set up an inflammation
known as sialoductilitis. These may consist of bristles, fish-bones,
and the like. Abscess, in consequence, may form in the gland or
between it and the foreign body. Calculi also lodge in the ducts,
where they remain as foreign bodies, producing sometimes a
disproportionate amount of irritation.

FISTULAS OF THE SALIVARY DUCTS.

Fistulas of the salivary ducts involve Stenson’s duct. They open on
the inside of the buccinator muscle, back of the orifice of the duct,
which is opposite the second upper molar tooth. These fistulas of the
parotid gland may be recognized by the passage of a probe from
within the mouth. When they open externally they result nearly
always from injury, and it is only the external forms which are
troublesome. One may resort to the mildest measures first, and
experiment with cauterization of the orifice or compression by
occlusion. These measures will be ineffective if there be no opening
upon the inside of the mouth, in which case one must be made by
reëstablishing the original canal or forming a substitute. For this
purpose a suture may be passed around the duct, back of the fistula,
using a curved needle, and making it come out near the point of
entrance. It should hold the duct in its loop. This suture may then be
tightened and the distended duct punctured on the inside of the
cheek. When once the flow of saliva is diverted to the mouth the
edges of an external fistula may be pared and closed. In obstinate
cases which have resisted all other methods it has been suggested
to remove or destroy the gland which connects with the duct at fault.
Even this is not an easy matter, but it can be done in the case of the
parotid by careful dissection, with separation of the branches of the
facial nerve and removal of the greater portion of the gland itself.
Congenital anomalies of the salivary glands are rare and of small
import. Any one of them may be displaced, or either of them may
connect with an accessory gland separated from it by an appreciable
interval. Abnormal duct openings have also been noted.

INFLAMMATION OF THE SALIVARY GLANDS.

Inflammatory affections of the salivary glands give rise to
sialoadenitis. Among these by all means the most common is
parotitis (mumps), which often occurs in epidemic form. It is an
infectious and probably contagious disease, usually attacking the
young, though no age is exempt. The period of incubation is about
fourteen days. The condition begins with a stomatitis and with
swelling of the affected parotid, with edema of the overlying tissues.
It is accompanied by moderate fever. Swelling may be extensive and
involve the entire neck region. The parotid on the other side
becomes affected within a few days, although usually not to a similar
extent. The other salivary glands occasionally participate. The febrile
stage lasts for about a week, after which the swelling recedes and is
gone within from two to four weeks. Occasionally the affected glands
suppurate, in which case the condition may be very serious, since it
may simulate Ludwig’s angina, or may be followed by sloughing and
gangrene.
Save when abscess threatens the treatment should consist of
warm antiseptic mouth-washes and the external application of an
ichthyol-mercurial ointment or of Credé’s silver ointment. When
suppuration threatens early incision should be made for the relief of
tension and prevention of destruction.
A frequent and important complication of parotitis is orchitis, or
swelling of the testicle. This is an unexplained feature of these
cases, and occurs mainly in sexually mature individuals. It is the
testis proper which suffers and not the epididymis. Suppuration here
is rare. More or less atrophy is a remote consequence in many
cases, estimated at about one-third. When both testicles are affected
to a marked degree impotency may follow. Treatment of this orchitis
consists in absolute rest in bed, with elevation of the parts affected,
often with the application of an ice-bag. Painting the scrotal skin with
guaiacol in small amount will often relieve pain. A similar
complication occurs in the female, the ovary being involved. Aside
from this, other complications may occur in the breast, the
vulvovaginal glands, the prostate, the heart, the eye, and the ear.
Apart from this somewhat specific affection the parotid and the
other salivary glands may become involved in swelling and
inflammation on account of surrounding local infections, or the
presence of foreign bodies, stones in the ducts, etc. Metastatic
abscesses, especially in the parotid, are not uncommon. Considering
the open pathways offered it is surprising that these glands are not
oftener involved in septic conditions of the mouth.

MIKULICZ’S DISEASE.
Mikulicz has described a not very infrequent simultaneous
affection of two or more of the salivary glands, occurring in middle
age, characterized by uniform swelling which may involve even the
palatine, labial, and buccal glands. It is spoken of in German
literature as Mikulicz’s disease. The swelling progresses slowly, so
that the glands reach a varying size in the course of years. Thus the
parotid glands may attain the size of the fist, and other glands a
corresponding increase. Sometimes the adjoining lymphatics are
also involved. The enlargements are not tender, but may interfere
with movements of the tongue and jaw. These tumors have been
known to recede after an intercurrent acute disease. Nothing is as
yet known of the cause or nature of the affection. In its treatment
arsenic and potassium iodide have given perhaps the most favorable
results.
The salivary glands, especially the parotid, are as likely to be
involved in the manifestations of tuberculosis, actinomycosis, and
syphilis as are the other structures of the body. Lesions of these
various natures will be appreciated without further description.

TUMORS OF THE SALIVARY GLANDS.

Tumors of the salivary glands are not uncommon. The parotid is
more frequently affected than either of the others. These tumors may
be of cystic character, either large from obstruction of the excretory
duct, or small and numerous. Almost all the tumors described in
Chapter XXVI may be found in this region. Simple adenomas are
common and the parotid especially is often the site of tumors of
mixed character, in which the various mesoblastic elements mingle
in a confusing manner. Cartilaginous tumors here are frequent. The
presence of cartilage is to be explained on Cohnheim’s hypothesis.
Endothelioma, sarcoma, and carcinoma are also common, especially
as primary tumors in the parotid. Any or all of the glands may also
suffer by extension of malignant disease from primary foci in their
neighborhood (Figs. 463 and 464).
 Fig. 463 Fig. 464

Mixed tumor of the parotid. (v. Bruns.) Mixed tumor of the submaxillary gland.
(v. Bruns.)

Cancer of the parotid is especially serious and discouraging,

because, while radical removal is necessary, it is impossible to effect
this without destroying the facial nerve and producing consequent
paralysis of the face on that side. Such an operation should not be
made without explaining to the patient beforehand its inevitable
result. Only when seen in their very early stages can these tumors
be so effectually removed as to not leave the patient liable to
secondary or metastatic affections. This also should be explained to
them in order that the surgeon may protect himself from blame.

SALIVARY CALCULI.
Calculi which form either in the substance of the glands, or much
more commonly in their ducts, by precipitation of those salts held in
solution by the saliva, are of the same character as the
accumulations of the so-called tartar upon the teeth. They are met
with frequently in Wharton’s duct and occur more often in men than
in women. They may vary in size from that of a rice-grain to a stone
more than one inch long. They are always ovoid in shape and with a
rough exterior. They are believed to grow much as do gallstones, as
the result of some previous infection, a clump of bacteria perhaps
affording the nidus on which calcareous material is deposited. The
affection may be spoken of as sialolithiasis.
They usually give rise to pain and swelling, and lead occasionally
to the formation of abscess and fistulous openings. They may be
revealed by the x-rays, or the operator may search for them as for
stone in the bladder, with a small probe passed through the duct
opening. The discharge of mucopus or blood into the mouth would
suggest infection of this kind. They may also be recognized by
thrusting a needle through the overlying tissues in the direction of the
swelling which they produce. Their removal through the smallest
incision on the interior of the mouth which will suffice for the purpose
is indicated. No attempt need be made to close the opening.
Operations on the parotid region are difficult and severe. In case
of large tumors the external carotid and the common carotid may be
ligated. By separating the patient’s jaws the parotid space is
increased and deep dissection is more easily made. Caution should
be taken not to open the maxillary joint. Souchon has called attention
to the fact that the safest plan is to proceed so long as the
surrounding tissues are easily removed en masse, and to stop when
they become too resistant as the deep surface is approached. Then
the portion of the tumor which has been cleared should be cut off.
The stump thus left will, in growing again, become more superficial,
and it is sometimes possible to effect a radical removal by a second
operation.
 CHAPTER XL.
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.

Fig. 465 Fig. 466

Double cleft palate. 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).
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 Fig. 467
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 Left-sided hare-lip and cleft palate. Marked
upper jaw to grow displacement of intermaxillary bone. Boy, aged six
years. (Bevan.)
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.
 Fig. 468 Fig. 469

Uranoplasty, showing Staphylorrhaphy, sutures placed. (König.)

incisions. (Tillmanns).

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