| At 3 years. | At 11 years. | ||
|---|---|---|---|
| Intervals between | canines | 24 mms. | 26 mms. |
| ” | 1st premolars | 26 ” | 29 ” |
| ” | 2nd premolars | 29 ” | 32 ” |
| ” | 1st molars | — | 34 ” |
CHAPTER IX.
SYPHILITIC AFFECTIONS OF THE PALATE.
This small work will not be complete without some allusion to the destructive effects of syphilis upon the hard and soft structures of the palate, resulting either in loss of substance of the velum, or in the production of apertures which of necessity impair its functions in the same way as do congenital deformities. They occur at different stages of the disease, but mainly in cases which have been neglected, and of which the treatment has been unsatisfactory.
In the secondary period the most common manifestation of this disease in the palate is, in its mildest form, simply a moderate injection of the mucous membrane, similar to the roseola seen on the skin. It is situated mainly on the velum and anterior pillars of the fauces, and under efficient treatment soon disappears. Severer manifestations are, however, met with, from the mucous plaque, with its resulting “snail-track” ulcer, to the most serious forms of destructive change. Such severe forms occur usually towards the close of the secondary period, and in persons of vitiated constitution. The process starts in the neighbourhood of the uvula, and involves the velum and pillars of the fauces; the mucous membrane and submucous tissue become hyperæmic and infiltrated with the products of inflammation, and the hyperplasia may be such as even to suggest the presence of epithelioma. Ulceration soon follows, and if the disease be extensive the patient’s condition may become serious from the difficulties experienced in deglutition and respiration. The loss of substance may extend to a variable depth, and subsequent cicatrisation tends more often to produce pharyngeal stenosis than to leave permanent apertures in the velum; as a result, speech becomes indistinct, and the act of swallowing is much interfered with. In many of these cases the primary sore has been intentionally or accidentally overlooked, or no treatment adopted.
In the tertiary stage the disease usually commences as a gummatous infiltration of the periosteum of the hard palate, resulting in an inflammatory swelling which softens and breaks down, the mucous membrane over it giving way; portions of the bony palate are thrown off at a later date with the discharge, in the form usually of “crumbly” spongy sequestra of variable size. This process often extends beyond the palate to the bones of the nose, to the walls of the antrum, and to the alveolar border of the superior maxilla. After cicatrisation has taken place, apertures of varying extent are left bounded by dense fibro-cicatricial tissue, which in some measure tends by its contraction to diminish the size of the opening. Clear articulation is impossible under these circumstances.
Similar conditions occur in inherited syphilis, leading to destruction of the bony palate, but in these cases the disease usually extends downwards from the nose.
The treatment of these affections need not here be discussed in detail so far as regards the general means to be adopted. What we are chiefly concerned with is the question as to the possibility of surgical interference with a view to closing the apertures, so as to improve the speech and increase the patient’s comfort by preventing the regurgitation of fluids from mouth to nose, and the descent of nasal mucus on to the tongue. The result, however, of the experience of all surgeons tends to prove that in the majority of cases any operative interference is worse than useless, and is likely to increase existing mischief. The chief reasons for the want of success are (1) that so much loss of substance has already occurred; (2) that the tissue dealt with is cicatricial, and consequently of low vitality; and (3) that the constitutional condition of such patients is extremely unfavorable for plastic work. Although I have myself repeatedly attempted the closure of apertures in the hard palate, I cannot recall a single case in which complete success was attained when the operation was performed on middle-aged individuals. On the other hand, small holes in the soft palate can in many instances be successfully dealt with, and I should not hesitate to attempt the closure of a small opening in the hard, provided that there was a reasonable prospect of gaining sufficient tissue to be brought together without tension after paring the edges, and that no external manifestation of local or general disease was present. When any such operation is decided on, the only hope of success consists in an absolute freedom from all tension, gained by extensive lateral incisions.
The application of lunar caustic or nitric acid for the purpose of closing small foramina is of doubtful utility on account of the feebleness of the tissues dealt with.
In most instances, therefore, we are compelled to have recourse to the use of obturators, and these are now made to accurately fit the opening without undue pressure on the sides. Two discs of india-rubber united by a central stem generally answer the purpose satisfactorily, and a plate may be worn fixed to one or more of the teeth. In hospital patients a piece of sheet india-rubber, which they fit for themselves, and maintain in situ by suction, is a cheap and efficacious contrivance.