ON HARELIP AND CLEFT PALATE.




                                    ON
                            HARELIP AND CLEFT
                                 PALATE.

                                    BY
                 WILLIAM ROSE, M.B., B.S.LOND., F.R.C.S.,
      PROFESSOR OF SURGERY IN KING’S COLLEGE, LONDON, AND SURGEON TO
                      KING’S COLLEGE HOSPITAL, ETC.

                                 LONDON:
                   H. K. LEWIS, 136 GOWER STREET, W.C.
                                  1891.




                              To the Memory
                                    OF

               SIR WILLIAM FERGUSSON, BART., F.R.S., LL.D.,
  SERGEANT-SURGEON TO THE QUEEN; PROFESSOR OF CLINICAL SURGERY IN KING’S
   COLLEGE, LONDON, AND SENIOR SURGEON TO KING’S COLLEGE HOSPITAL, ETC.

                         In Grateful Remembrance
                                  OF HIS
                   EXCEPTIONAL KINDNESS FOR MANY YEARS
                  BOTH AS A TEACHER AND PERSONAL FRIEND,
                                   AND
                          In Humble Recognition
                                  OF HIS
                       MASTERLY SKILL AS A SURGEON,
                           THIS SMALL VOLUME IS
                        AFFECTIONATELY DEDICATED.




PREFACE.


In bringing this book before the notice of the profession I have given
the results of my experience, which has now been considerable, in a
department of surgery always of special interest to me, and to which I
have devoted particular attention. The privilege enjoyed for many years
of assisting the late Sir William Fergusson gave me an early insight into
these operations, and an unusual opportunity of learning their details at
the hands of so distinguished a surgeon. I have endeavoured to make the
work as complete as possible, and to bring its contents up to date, and
in this am greatly indebted to the assistance of my colleague Mr. Albert
Carless, who has not only revised the whole work, indexed it, and seen
it through the press, but has also written the chapter on Development. I
gratefully acknowledge the kindness I have received from various sources
in permitting the use of blocks for illustrations, notably from Mrs.
Mason, the widow of the late Mr. Francis Mason, whose work on the subject
is well known, from Mr. Oakley Coles, and many others, whose names will
be found in the list of illustrations.

17, HARLEY STREET, W.; 1891.




CONTENTS.


                                                                      PAGE

                               CHAPTER I.

                          GENERAL INTRODUCTION.

    Harelip—Cleft palate—Frequency—Occurrence in animals—Associated
    deformities—Median harelip—Facial clefts—Macrostoma—Mandibular
    clefts—Causes of these deformities                                1-25

                               CHAPTER II.

              ANATOMY AND PHYSIOLOGY OF THE NORMAL PALATE.

    The hard palate—The velum and its muscles—The mucous
    membrane—The blood supply—The shape and size of the hard
    palate—Functions                                                 26-35

                              CHAPTER III.

                              DEVELOPMENT.

    Normal development of mouth, face, nose, and
    teeth—Ossification—Development of intermaxilla; old ideas
    (Goethe’s, &c.); Albrecht’s theory—Harelip; position of cleft
    in alveolus, and in lip—Dentition; accessory teeth—Development
    of other deformities                                             36-59

                               CHAPTER IV.

         THE ANATOMY AND PHYSIOLOGY OF HARELIP AND CLEFT PALATE.

    Harelip—Effect of labial muscles on deformity—Structure of os
    incisivum and labial segments.

    Cleft palate—Arrangement and action of muscles—Shape
    of bony segments—Associated irregularity in shape of
    skull—Physiological effects in nutrition, articulation, &c.      60-71

                               CHAPTER V.

                     OPERATIVE TREATMENT OF HARELIP.

    Period of operation—Statistics—Precautions to be adopted.

    Operation for single harelip: incisions; sutures; dressing;
    after-treatment—Various plans adopted.

    Operation for double harelip: treatment of os
    incisivum—extirpation or reposition; treatment of soft parts    72-100

                               CHAPTER VI.

                  OPERATIVE TREATMENT OF CLEFT PALATE.

    Period of operation—Preparation of patient—Anæsthesia—Duties
    of the assistant—Instruments—Description of uranoplasty; of
    staphyloraphy—After-treatment—Complications—Modifications of
    the operation                                                  101-138

                              CHAPTER VII.

    ON OBTURATORS AND ARTIFICIAL VELA                              139-145

                              CHAPTER VIII.

    RESULTS OF TREATMENT—AFTER-TREATMENT                           146-153

                               CHAPTER IX.

    SYPHILITIC AFFECTIONS OF THE PALATE                            154-156

                                ADDENDUM.

    RECTAL ANÆSTHESIA                                             157, 158

    INDEX                                                              159




LIST OF ILLUSTRATIONS.


     1. Hare’s lip (_Bland Sutton_).

     2-6. Different varieties of harelip (after _Tillmanns_).

     7, 8. Double harelip with projection of os incisivum, seen from
         the front and in profile (_Fergusson_).

     9. Complete cleft palate with double alveolar harelip (_Mason_).

    10. Complete cleft palate without alveolar or labial deformity
          (_Mason_).

    11. Complete unilateral cleft palate with vomer attached to one
         segment (_Mason_).

    12-14. Incomplete fissures of the palate (_Mason_).

    15. Cleft of lip, alveolus, and anterior part of palate only
         (_Mason_).

    16. Median harelip with absence of intermaxillæ (_Bland
         Sutton_).

    17. Median fissure of upper lip (_Bernard Pitts_).

    18. Oblique facial cleft (_Tillmanns_, after _Kraske_).

    19. Facial cleft in child (_Tillmanns_, after _Hasellmann_).

    20. Double facial cleft with macrostoma (_Tillmanns_, after
         _Guersant_).

    21. Puppy’s head with double alveolar harelip and double
         partial facial cleft (after _Albrecht_).

    22. Lateral aspect of a severe case of macrostoma (_Bland
         Sutton_).

    23. Double macrostoma with auricular appendages (_Tillmanns_).

    24. Ditto ditto (_Fergusson_).

    25. Mandibular cleft (_Wölfler_).

    26. Intermaxillary sutures of a tetraprodontous child’s jaw
         (after _Albrecht_).

    27. Intermaxillary sutures in a hexaprodontous jaw (after
         _Albrecht_).

    28. Muscles of palate dissected (_Fergusson_).

    29. Head of fœtus at 5 weeks (_Sutton_).

    30. Head of fœtus at about 6-7 weeks (_Sutton_).

    31A. Head of fœtus at about 8 weeks, from the front (_Quain’s
         Anatomy_).

    31B. Head of fœtus seen from below (_Quain’s Anatomy_).

    32, 33. Later stages of development of head (_Quain’s Anatomy_).

    34. Diagram of development of palatal processes and
         ethmo-vomerine plate (after _Gegenbaur_).

    35. Bony palate of a 6 months’ fœtus (after _Gilis_).

    36. Diagram illustrating “Goethe” theory of alveolar harelip.

    37. Diagram illustrating “Albrecht” theory of alveolar harelip
         in a tetraprodontous jaw.

    38. Diagram illustrating “Albrecht” theory of alveolar harelip
         in a hexaprodontous jaw.

    39. Adult upper jaw with right-sided alveolar harelip and cleft
         palate (after _Albrecht_).

    40. Child’s jaw with cleft palate and double alveolar harelip,
         showing the sockets of the teeth (after _Albrecht_).

    41. Os incisivum (_Fergusson_).

    42, 43. Diagrams illustrating the effect of differing slopes of
         the palatal segments (_Mason_).

    44. Teat of feeding bottles adapted for feeding infants with
         cleft palate (_Mason_).

    45. Coles’s nipple shield for ditto (_Coles_).

    46A and B. Author’s incisions for unilateral harelip, and
         position of sutures.

    47A and B. Graefe’s operation for unilateral harelip.

    48A and B. Nélaton’s ditto.

    49A and B. Malgaigne’s ditto.

    50A and B. Giraldés’ ditto, or the mortise operation.

    51A and B. Mirault’s ditto.

    52. Stokes’s ditto (_Mason_).

    53A and B. Collis’s ditto (_Mason_).

    54A and B. Author’s incisions for double harelip.

    55. Sédillot’s operation for ditto (_Mason_).

    56. T. Smith’s operation for ditto (_Mason_).

    57. T. Smith’s gag with tongue plate (_Messrs. Arnold and Son_).

    58. Mason’s gag (_Matthews Bros._).

    59. Rose’s gag (_Matthews Bros._).

    60. Various forms of raspatories (after _Durham_).

    61A. Fine hook forceps.

    61B. Smooth-nosed forceps.

    61C. Knife for paring edges of cleft (_Mason_).

    62. Angular long-handled catch forceps.

    63. Various forms of needles.

    64, 65. Diagrams to illustrate the effects of tightening the
         sutures on the needle-tracks.

    66. Wire twister (_Messrs. Maw, Son, and Thompson_).

    67A. Diagram to show extent and position of incisions in
         uranoplasty.

    67B. Diagram of position of sutures and condition of palate
         after operation.

    68. Double-curved raspatories.

    69. Loop method of passing sutures (_Mason_).

    70. Method of tying slip-knot (_Fergusson_).

    71. T. Smith’s palate needle (_Messrs. Arnold and Son_).

    72-74. Various form of artificial vela (_Coles_).

    75. Appearance in profile after operation for double harelip,
         including removal of os incisivum (_Coles_).




ON HARELIP AND CLEFT PALATE.




CHAPTER I.

GENERAL INTRODUCTION.

    _Harelip—Cleft palate—Frequency—Occurrence in
    animals—Associated deformities—Median harelip—Facial
    clefts—Macrostoma—Mandibular clefts—Causes of these
    deformities._


The congenital fissures and deformities of the mouth and lips form a
group which is considerably larger than might be imagined from the
scanty notice given them in ordinary text-books; and although many are
extremely rare, yet possibly if more attention were drawn to them, fresh
cases would be noted and recorded, and the somewhat scanty materials from
which we have to work out their development and characteristics would
be increased. In order to facilitate subsequent description, I append
a classified list of the deformities which we shall pass under notice,
premising that the more practical part of this work will be occupied
exclusively with two of them.

Six different classes may be described:—

(1) Median harelip (inter-intermaxillary).

(2) Ordinary harelip (intermaxillary).

(3) Facial cleft (maxillo-intermaxillary).

(4) Buccal cleft, or macrostoma (maxillo-mandibular).

(5) Mandibular cleft, or median fissure of the lower lip.

(6) Cleft palate.

Inasmuch as ordinary harelip and cleft palate are the conditions most
commonly met with, it will be convenient to describe them first, alluding
subsequently to the others.


HARELIP.

French, _bec-de-lièvre_. German, _Hasenscharte_—or if with complete cleft
palate, _Wolfsrachen_ (wolf-jaw).

[Illustration: FIG. 1.—Hare’s lip to show the median cleft in the lower
part prolonged upwards into either nostril. (_Sutton._)]

Harelip is a congenital deformity of the upper lip, characterised by a
cleft extending for a variable depth, either through the soft tissues of
the lip only, or implicating in addition the alveolus, floor of the nose,
and palate. No mention of this condition is made by Hippocrates, Galen,
or any of the fathers of medicine; and so far as I can discover the name
is first used by Ambrose Paré, who probably initiated the treatment by
pin and figure-of-8 suture. The name is really a misnomer, in that the
condition (as has been many times pointed out, but notably by Fergusson)
does not simulate a hare’s lip except in the fact of being cleft, for
the natural cleft in the animal’s lip is always in the median line
below, bifurcating above to reach either nostril (Fig. 1), whereas in the
abnormal human lip the cleft lies to one or the other side. Instances of
median defect are known, but they are extremely uncommon, and consist
often of more than a simple fissure.

[Illustration: FIG. 2. FIG. 3. FIG. 4.

FIG. 5. FIG. 6.]

The deformity may exist as a simple notch in the soft tissues of the
lip, unilateral (Figs. 2 and 3) or bilateral (Fig. 4); when more
decided, it may implicate one or both nostrils (Figs. 5, 6, and 7). In
mild cases the alveolus is intact; in others, cleft, constituting the
variety known as _alveolar harelip_, and the line of fissure may, or may
not, extend backwards into the palate. In all cases of double alveolar
cleft, the palate is also involved, and the central parts of the lip
and intermaxilla tend to project forwards; in the severest forms these
portions are completely isolated from the maxillæ, and, supported by the
vomer and septum nasi, form a proboscis-like appendage to the end of the
nose, which is excessively disfiguring. (Figs. 7 and 8 illustrate this
deformity as seen from the front and in profile.)

The shape of the nose in unilateral harelip is very characteristic,
being broad and flattened out from the deficiency of the floor and
posterior wall of the anterior nares.

[Illustration: FIGS. 7 AND 8.—Double harelip with projection of the os
incisivum, as seen from the front and in profile. (_Fergusson._)]

Harelip seems to occur more commonly in boys than in girls. According to
Müller, out of 270 cases, 170 were boys, and 100 girls.

Unilateral harelip is more commonly met with on the left side than on
the right; probably 60-70 per cent. of the cases are left-sided. Thus
Müller reports 142 left-sided against 62 right-sided clefts; Mason, out
of 65 cases, found 54 to be unilateral, and of these 35 left-sided to
19 on the right; Kölliker mentions that in 165 unilateral clefts, 113
were on the left side, and 62 on the right. My own experience quite
coincides with these figures. At present, no satisfactory explanation
of this preponderance of left-sided clefts has been given. One solution
suggests itself, but we have no facts of importance to support it, viz.
that, inasmuch as the majority of people are from heredity or education
right-handed, Nature devotes more energy to completing her developmental
processes on that side than on the left, and any check to this would
be more likely to happen on the left side. It would be valuable and
interesting to know in what proportions other unilateral deformities
occur on the left and right sides respectively.

Occasionally one sees in the upper lips of children a congenital red line
_apparently_ cicatricial, occupying the position of the normal harelip
fissure, and which has been supposed to indicate a natural cure of a
temporary defect of development. My colleague, Mr. Carless, has recently
shown me a case of this character under his care in a child a few weeks
old. There was a well-marked red line extending from the lip margin to
the nostril; but there was no irregularity in the red border, and no
evidence of cicatricial contraction; the tissue of the lip, moreover,
seemed quite soft and normal, not fibrous or hard. These points seem to
bear out fully Trendelenburg’s opinion[1] that the name “intra-uterine
cicatrisation or cure of a harelip” is incorrect, and that such cases
are simply due to the raphe of union remaining evident instead of
disappearing as usual; and he quotes the normal appearance of the raphes
in the scrotum and perinæum as similar conditions. In this child there
was no evidence of any groove or depression in the alveolus; but other
deformities were present, viz. a very definite post-anal dimple, the
cicatrix being adherent to the tip of the coccyx, a slight condition
of hypospadias, and a congenital hydrocele. There was no history of
deformity in the family, nor of maternal impression.


CLEFT PALATE.

This is a congenital deformity due to non-closure of the horizontal
palatine outgrowths extending inwards from the maxillary processes. The
name must not be applied to acquired fissures or defects of the palate
due to injury or to disease of the bones later in life. (See Chap. IX.)

As with harelip, so with cleft palate, the extent of the defect varies
greatly in different cases. Thus in the most severe forms, there is a
total mesial longitudinal cleft, extending forwards from the tip of the
uvula to the level of the anterior palatine canal, thence bifurcating to
communicate anteriorly with a double alveolar harelip, the os incisivum
or central portions of the intermaxilla being usually displaced forward
(Fig. 9). Such a condition is known by German authors as “Wolfsrachen,”
or wolf-jaw. The vomer descends in the median line usually into close
quarters with, but separate from the margins of the cleft, and the os
incisivum is attached to its anterior extremity. When the vomer comes
far down and is well developed and prominent, and the palatal outgrowths
small, the cleft appears to be double, but is not so in reality (Figs. 9
and 10).

[Illustration: FIG. 9.

FIG. 9.—Complete cleft palate and double alveolar harelip; simulating
a double lateral cleft, due to the vomer being seen free between the
palatal segments. (_Mason._)]

[Illustration: FIG. 10.

FIG. 10.—Complete cleft palate without alveolar or labial deformity; the
vomer is separate from the lateral segments. (_Mason._)]

[Illustration: FIG. 11.—Complete unilateral cleft palate without alveolar
deficiency; the vomer is attached to the left palatal segment. (_Mason._)

FIGS. 12, 13, 14.—Various degrees of simple fissure of the palate.
(_Mason._)]

Not unfrequently the vomer is attached to one of the margins of the
cleft, this condition being usually associated with unilateral alveolar
harelip. Such attachment always occurs on the side opposite to the
fissure in the alveolus; that is to say, since unilateral harelip is
more common on the left, the vomer is usually attached to the right side
of the cleft. Fig. 11 indicates the less common condition of attachment
of the vomer to the left palatal segment. Rouge[2] and Oakley Coles[3]
fully confirm this statement. The cleft may, however, merely implicate
the soft and hard palate, leaving the alveolus and lip perfect, and does
not then extend further forward than the site of the anterior palatine
canal, and is strictly median (Fig. 12); or it may be still more
limited, involving more or less of the velum, perhaps only the uvula, or
extending a variable distance into the hard palate (Figs. 13 and 14).

[Illustration: FIG. 15.—Unusual form of cleft involving the alveolar
arch, and the anterior portion of the palate only. (_Mason._)]

Other less common congenital deformities have been recorded, and amongst
them may be noted a case lately seen by myself in a girl of four years,
in whom there existed an oval opening at the junction of the hard and
soft palate, separated by a narrow bridge of normal palatal tissue from a
cleft of the posterior half of the velum and uvula, showing intermissions
of development; a congenital aperture in the soft palate at its junction
with the hard, or in any part of the velum, but with no defect of either
uvula or palate bones (Dieffenbach[4]); a defective development of the
palate bones alone, the mucous membrane remaining intact from side to
side, and hence no cleft resulting (Trélat, Notta, Langenbeck); or again,
as in Fig. 15, a cleft only of the anterior portion of the palate,
extending through the alveolus, and for a short distance behind it
(Mason[5]). Inasmuch as the union of the two halves of the velum occurs
subsequently to that of the alveolar arch, it appears that this last
rare defect must have been due to an intermission of development, which
was felt only at the anterior portion, whilst that of the posterior part
proceeded normally at a later date.

Mason[6] records a curious case worth mentioning of a girl under his
care in 1877, who had a fissure extending through the velum, and for a
short distance into the hard palate, but there was no trace of uvula on
either side, and the soft palate was continuous on both sides with the
pharyngeal wall.

The width of the cleft varies as much as the extent, and is a matter of
great importance prognostically, as the broader clefts are much more
difficult to close. The direction or slope of the segments of the bony
palate also differs considerably, in some instances being more or less
horizontal and following the normal curve; in others one or both of the
segments is much more nearly vertical, a condition which is not at all
unsatisfactory, for, as will be explained hereafter, the more horizontal
the palatal processes, the more difficult is it to gain satisfactory
closure by operation (p. 65).

       *       *       *       *       *

The frequency of the occurrence of harelip and cleft palate cannot
accurately be ascertained, inasmuch as statistics are not readily to be
found. In the ‘St. Thomas’s Hospital Reports’ the number of malformations
of the children born is noted in some of the years. Thus the aggregate
number of living children born in their maternity department in the years
1875, 1877-1880, and 1883 was 10,653, and of this number there was only
one case of harelip, with two cases of cleft palate, and three of the
combined deformity, _i. e._ about one case in every 1800 infants born;
but if the silence of the reports for subsequent years means absence of
deformity, then this proportion may be much too great.

On the Continent some old records are obtainable. Thus, according to
Grenser, of 14,466 infants born living at the Maternity at Dresden from
1816 to 1864 there were sixteen cases of simple harelip, and nine with
fissures of the palate. Credé states that amongst 2044 infants examined
at birth, only one case of simple harelip was observed, and one of
complete division of the hard and soft palate.


OCCURRENCE IN ANIMALS.

These conditions obtain not only in the human subject, but also in
animals, though not so commonly.

Thus Sutton figures a right-sided harelip in a slink calf, and mentions
a specimen of a harelip in a lamb in the museum of the Odontological
Society; and in our museum at King’s College there is a specimen of a
right-sided harelip in a kitten with a cleft alveolus, but the palate is
intact.

Cleft palate occurs more frequently in animals, particularly in those
born in a state of captivity. Thus it appears that from statistics taken
ten years ago 99 per cent. of the lion cubs born in the London Zoological
Gardens had cleft palates, indicating that either the food-supply of
these animals was not all that was requisite for perfect development,
or that enforced confinement has a deleterious effect upon the
multiplication of the species. It is a curious fact that in the Dublin
Zoological Gardens the deformity was rarely noticed amongst the lion
cubs, and the reason for this was supposed to be the supply of such food
that the mother could eat both flesh and bone. Since the same practice
has been followed in London, viz. giving the lions twice a week a young
goat which they can eat, bones and all, the proportion of cleft palates
in the young subsequently born has become considerably diminished.


ASSOCIATION WITH OTHER DEFORMITIES.

Occasionally, besides the fissured palate or lip, other deformities
are noted in the same patient, but not so often as one might be led to
expect. Mason records two or three cases as having come under his notice,
the coincident deformities being respectively fistulous openings of
buccal glands in an everted lower lip, congenital fissure of the lobe
of the right ear, congenital talipes calcaneus and hypospadias. Dr. F.
Warner records in the ‘Medical Times and Gazette,’ January, 1882, some
cases of cleft palate associated with congenital defects of the heart
and smallness of head, and also notes in his more recent report[7] that
in 117 cases of malformations of the palate, other than cleft, only
42 were not in combination with other defects. Thus in 55 cases there
were abnormalities in the shape of the cranium, in 16 cases defective
development of the ear, in 12 the existence of an epicanthic fold, and in
15 cases other defects not tabulated.

Clutton[8] records and pictures a curious development of a flap of
mucous membrane on the lower lip of a woman with a cleft palate; it was
triangular in shape, and with overhanging projecting angles. The teeth in
this case were likewise badly developed, and were all extracted at the
age of nineteen.

Binet[9] reports a case of an old cured right-sided harelip in a man dead
from apoplexy (æt. 53 years) with infantile genital organs.

Broca[10] describes a much deformed fœtus, stillborn at seven months,
which he dissected, showing a double harelip and cleft palate, but the
os incisivum retained its usual position, thanks to its mucous covering.
The dentition,[11] as noticed elsewhere, was also interesting, and the
buccal deformity was associated with a congenital diaphragmatic hernia,
and an abnormal condition of the heart and great vessels.

Other associated malformations are on record, _e. g._ an extra thumb
on each hand; and Sir Morell Mackenzie has reported a case in which
there was a congenital fissure between the arytænoid cartilages with a
trilobate epiglottis, occurring in conjunction with harelip and cleft
palate.[12]

       *       *       *       *       *

The remaining deformities to be noticed here are much less common, but
demand attention by their rarity and interest, and on account of the
light they throw on the embryology of the lip and mouth.


MEDIAN HARELIP.

This is an exceedingly rare phenomenon, and for long the possibility
of the existence of such a condition was doubted. Supposed cases were
explained by imagining that from some unknown cause a lateral fissure
had been drawn over to the median line. But at the present time there
are records of several, mainly, however, in German works; in our own
literature there are but few references to the subject. Two varieties of
median defect have been described; and the distinction between these has
been carefully and thoroughly made by Trendelenburg.[13]

1. _Double cleft of the upper lip with failure of development of the
intermaxilla._ Some half-dozen cases of this are indicated in his work;
but perhaps one of the best descriptions is that recently given by Bland
Sutton,[14] and from whose paper the accompanying picture is obtained
(Fig. 16). It occurred in the practice of Mr. Treves, and died within a
few weeks of birth. There was a broad median defect, flanked laterally by
the curved convex borders of the maxillary processes; the intermaxillæ
were entirely absent, and the nose quite flat. In addition to this
the eyes were affected with coloboma, the right eye presenting other
serious defects. “On examining the child before its death,” the author
states, “I felt convinced that there was no ethmo-vomerine plate, and
this conviction was strengthened by the peculiar shape of its forehead.
When the child died, this opinion was fully confirmed; there was no
ethmo-vomerine plate, consequently no nasal septum, and what is more
important, the premaxillary bones were absent.”

[Illustration: FIG. 16.—Median harelip showing total absence of the
central portion of the upper lip and of the intermaxillæ, and flattening
of the nose from absence of the ethmo-vomerine plate. (_Bland Sutton._)]

But according to the cases reported by Trendelenburg the defects do not
stop here. There is usually in addition a broad median palatal cleft,
and an absence of nasal bones and muscles; but Kundrat records two cases
where the palatal processes of the superior maxillæ and palate bones were
well developed, and united in the middle line. The skull itself has been
found defective occasionally, the whole cranial portion being small, and
the lamina cribrosa and crista galli of the ethmoid absent; in place of
these was a fossa between the orbital plates of the frontal bone with no
bony basis, but only dura mater covered with mucous membrane. No openings
for the passage of the olfactory nerves were found.

Hadlich has also described changes in the brain in two cases occurring
in Langenbeck’s clinique, consisting mainly in the amalgamation, more
or less, of the two hemispheres; the corpora striata and optic thalami
were united in the middle line, and the third ventricle, fornix, corpus
callosum and olfactory nerves were absent. It is interesting to note the
association of such an abnormal fusion of the lateral parts of the brain
in the median line with the defective development of the median parts in
the skull and face.

But the separation of the facial elements is not always maintained;
sometimes they fall or are drawn together by the united palate, resulting
in the so-called congenital atresia of the nose (“angeborene Atresia der
Choanen”), cases of which have been recorded by Luschka, Bitot and Engel.
The latter states that in an infant’s skull examined, only 2 or 3 mm. of
space existed between the orbits, and 4 mm. between the optic foramina.

2. _True median cleft of the upper lip_ with development of the
intermaxilla is an excessively rare occurrence, but a few cases have been
now recorded.

The simplest type consists of a cleft in the soft portions of the upper
lip with no other deformity, but a more complete variety of the defect
includes a median division of the nose.

Mr. Pitts, in the Medical Society’s ‘Proceedings’ (vol. xii, p. 304),
reported a case in a boy aged five months (Fig. 17). The cleft was
median, extending halfway up to the columna. The premaxilla was centrally
grooved but otherwise perfect. The palate was normal.

[Illustration: FIG. 17.—Median harelip, showing a mesial cleft in the
soft structures of the upper lip. (_Pitts._)]

A more aggravated condition has been dissected by Witzel (in the Rostock
Collection). Behind the cleft in the upper lip was found a median
division of the premaxilla, each half of which was firmly united to the
adjacent superior maxilla. The vomer was single, but broader than usual,
and the palate cleft throughout; the two halves of the nose were bounded
internally by separated plates of the divided cartilaginous nasal septum.
There was also a defect of the frontal bone giving rise to a meningocele.
This flattening of the nose, combined with separation of the anterior
nares, gave such an appearance to the face as seemed to warrant the term
“dog’s nose” (Doggennase) which has been applied to it.[15]


FACIAL CLEFTS (German, “_Schräge Gesichtsspalte_”).

[Illustration: FIG. 18.—Oblique facial cleft, or rather cicatricial
deformity of face along the line usually traversed by such a cleft.
(_Tillmanns_, after _Kraske_.)]

[Illustration: FIG. 19.—Facial cleft in a child, implicating the lower
lid and eye, and with a development of accessory teeth along the cleft
margins. (_Tillmanns_, after _Hasellmann_.)]

[Illustration: FIG. 20.—Double facial cleft with macrostoma.
(_Tillmanns_, after _Guersant_.)]

These are seldom seen, but a sufficient number are now recorded and
figured to enable us to study the nature of the defect. Sir W. Fergusson
seems the only English surgeon who has observed this rare condition,
the majority of recorded cases hailing from Germany or France. As we
shall see hereafter, this defect is due to the non-closure of the cleft
between the outermost part of the intermaxilla and the maxilla itself,
and occupies the position which was claimed up to recent years as that of
an ordinary harelip.

In several of the cases noted red cicatrices (Fig. 18) rather than
actual clefts (Figs. 19 and 20) were present. The defect begins at the
free margin of the upper lip, and usually at the spot whence starts the
ordinary harelip cleft; but occasionally from the angle of the mouth. It
then trends upwards and outwards, leaving the nose entire, and skirts
round the ala nasi to reach its upper limit at the middle of the lower
eyelid which is cleft, or at the inner canthus. The eye itself may show
a coloboma iridis, usually downwards and inwards. The facial skeleton
may be divided or not; sometimes a large opening into the antrum exists
(Hasellmann,[16] Kraske[17]). No incisor teeth are developed on the
outer side of the cleft, the first tooth seen being the canine. On the
inner border of the cleft lip there is usually a marked frænulum, often
smaller, however, than the normal median frænum.

This deformity may be unilateral or bilateral (Guersant, Meckel), more
frequently the former; and is not uncommonly associated with macrostoma
of the same or opposite side of the face (Guersant, Pelvet[18]), as seen
in Fig. 20.

Albrecht[19] records a most interesting case in a newly born pup (Fig.
21) of double clefts extending from the lip margin upwards not only into
the nostril, but also towards the eye on either side, _i. e._ a double
associated harelip and facial cleft. The specimen is taken from the Royal
Veterinary College of Brussels.

[Illustration: FIG. 21.—Front view of a young puppy’s head from a
preparation in the Veterinary College of Brussels, showing double harelip
with double partial facial cleft. (After _Albrecht_.)

_a._ Central portion of upper lip, corresponding to internal nasal
process. _b._ Ala nasi, corresponding to external nasal process. _c._
Outer portion of upper lip, from superior maxillary process. _d._ Harelip
cleft. _e._ Facial cleft.]

[Illustration: FIG. 22.—Macrostoma, showing the cleft in the cheek
prolonged upwards and backwards by a reddish cicatrix to a lateral loss
of substance of the cranial wall. (_Sutton._)]


MACROSTOMA

_Or commissural harelip_ (French, _bec-de-lièvre genien_; German, _Quere
Gesichtsspalte_, _Wangenspalte_, or _Grossmaul_) is a less uncommon
condition, evidenced by an increased transverse diameter of the mouth.
The oral aperture extends into one or both cheeks, and, if unilateral,
is more frequently on the right side. The cleft extends upwards and
backwards towards the auditory meatus, and sometimes towards the temple
to a variable extent. It may merely be manifested by a slight increase
in the breadth of the mouth, or may extend to a considerable distance,
as in a case reported by Rynd,[20] where the mouth-opening extended as
far as the first molar on the right side, and to the last molar on the
left. Sutton[21] has published drawings of a child (Fig. 22) in which a
very large cleft existed, the angles of which gradually passed into a
red cicatrix. This scar ended in a gaping recent wound over the temporal
region, extending to the dura mater, and through this, after death, the
convolutions of the brain were visible. The condition was symmetrical,
and he suggests that the wound in the skull was probably brought about
during parturition. The same author records a condition the very opposite
of this, where the defective closure of maxillary and mandibular
processes was reduced to a minimum, the deformity amounting to nothing
more than a fistulous opening through the cheek, with a small tumour
representing an accessory auricle just in front of the tragus.

Roulland[22] has recently reported an instructive case in which double
macrostoma existed with accessory auricular appendages, but this was
also complicated with an entire absence of the middle ear and of
the Eustachian tube, with defective development and absence of the
temporo-maxillary joint on the left side. Such a deformity is probably
to be explained by an excessive obliteration or partial development of
the maxillo-mandibular cleft at its posterior extremity, and a defective
obliteration of the same anteriorly.

[Illustration: FIG. 23.—Double macrostoma, showing the presence of
auricular appendages. (_Tillmanns._)]

[Illustration: FIG. 24.—Macrostoma with auricular appendages.
(_Fergusson._)]

Associated with macrostoma is often to be noticed some abnormal condition
of the external ear, either defective development or the production of
accessory auricles (Figs. 23 and 24). In a case of bilateral macrostoma
recently under my own care, there was a well-marked accessory auricle.
This complication was first pointed out by M. Debout.

One or two observers (Morgan, Colson[23]) have noticed a small papillary
projection on the red margin of the cleft, indicating the position where
the true mouth ended, and due to the insertion thereat of the divided
orbicularis oris.

For long the very existence of this macrostomatous deformity was
doubted, but cases have been recognised more or less since 1715, when
Muralt pictured it for the first time. A _résumé_ of all the earlier
cases has been made by M. Debout,[24] whilst Roulland[25] and Pilz[26]
have gathered together some of the later.

Macrostoma is not only attended by great disfigurement, but is also
troublesome from the impossibility of the child retaining its saliva, and
the food escaping during mastication. Suckling can be performed if the
nurse’s nipple be long, but is difficult otherwise. This deformity is,
perhaps, more frequently associated with defective cerebral power than
any other of the facial clefts, a large proportion of the subjects having
been idiots.


MANDIBULAR CLEFT.

This condition is one of the rarest that we have had to describe, so much
so that Roux and Cruveilhier denied its existence, and Fergusson had seen
but one case. Bouisson[27] in 1840 mentions some three or four earlier
cases, and records one that he had seen _post mortem_ himself. Since that
date some six or eight instances have been noted, and the latest, with
some excellent pictures, is described by Wölfler[28] (Fig. 25).

The cleft extends in different cases to a variable extent. Thus Nicati,
Couronue, F. Petit, and Ammon saw clefts implicating the lower lip alone.
Ribell[29] operated on a cleft extending to the chin, through which
the saliva was continuously dribbling. Faucon (1868) and Lannelongue
(1879) recorded clefts of the lip and mandible conjoined, and in both
cystic swellings (presumably of the dermoid type) were found between the
segments. Parisé’s (1862)[30] and Wölfler’s cases were also associated
with cleft of the tongue, through its whole thickness in the former, and
only at its tip in the latter.

[Illustration: FIG. 25.—Mandibular cleft, showing the divided lower lip,
the segments being held together by cicatricial bands. (_Wölfler._)]

In Parisé’s case the child was fourteen days old. The lower lip was cleft
through its whole thickness in the median line. The free edges were
rounded as in harelip, and the cleft was continued below as a cicatricial
band in the middle line of the neck as far as the sternal notch. The
mandible was in two portions, which were separated from one another by
a distance of two or three millimetres, bridged across by connective
tissue. The tongue was entirely divided, the cleft extending back to the
glosso-epiglottic ligament, and downwards between the genio-hyo-glossi
muscles; each half was covered throughout with mucous membrane, and
was bound to the corresponding side of the jaw by a mucous ligament or
frænulum.

       *       *       *       *       *

As to the _ætiology_ of these defects, but little is known.

_Heredity_ is an undoubted factor in their production, and an
investigation of the family history will in many cases elicit a
confirmation of such an idea. Thus in two instances in my own practice
I have been able to determine that the father, grandmother, and
great-grandfather had all suffered from harelip to a greater or less
extent. Mason in his book mentions several other illustrations of this
fact. Liston operated on four members of one family for harelip. M.
Demarquay[31] related a case in the Surgical Society of Paris, in which,
from the grandparents downwards, eleven children had been born with
harelip. In the ‘British Medical Journal’[32] a correspondent related his
own family history, stating that it had occurred in some branch or other
for the past hundred years.

An examination of the parents’ mouths should always be made when
possible, and very commonly it will be found that one or both possess a
short upper lip, and a high arched narrow palate. In others there is a
slight groove in the alveolar process between the central and lateral
incisors. I have also observed a small symmetrical crease on either side
of the median line in the upper lip, indicating a tendency to, if not a
natural intra-uterine cure of, a double harelip.

In some instances the deformity dies out of families, possibly from
the fact that the defective condition in one parent is remedied by a
more perfect development in the other; whilst in others the tendency
distinctly increases, and a father or a mother with harelip will beget
a family where three out of the four or five children will be similarly
affected. By a proper selection of mates this deformity could probably be
bred out, as well as bred up to.

The so-called _Maternal Impression_ is looked on, especially by the
laity, as another common cause of these deformities. Medical men will
usually receive histories of such with a smile of incredulity, and
rightly so; but some recorded cases, if true, are so definite that to
condemn such an explanation too dogmatically seems scarcely to indicate
a scientific spirit. The usual type of history given is that _after_ the
mother has seen the defect in the newly-born infant, she looks back over
the preceding nine months to see if there were any apparent cause for
the trouble, and seeking out particularly some shock or fright produced
by seeing something resembling the defect in her infant often selects
something trivial and irrelevant. The following authentic case is worthy
of mention:[33]

A child was born deformed by a left unilateral harelip. The mother
immediately asked to see the infant, declaring she was afraid it was
marked, and on seeing it manifested no surprise at the appearance of its
lip, stating that when about four months pregnant she received a fright,
from the shock of which she had not yet fully recovered. Startled by a
boy running almost into her arms, from whose face blood was streaming,
she had seen a cut in the left side of the upper lip, extending through
its substance into the nostril, laying bare the gums and teeth. She
turned faint with fright, and could not banish the thought even after
reaching home. The lad was subsequently examined, and the scar of a cut
was found in that position.

In spite of such facts, however, one hesitates somewhat in accepting
the antecedent alarm and the subsequent deformity in the relationship
of cause and effect. The imaginary “maternal impression” probably in
nine cases out of ten has nothing to do with the defect; whilst a real
“maternal shock” which possibly led to the production of the deformity
passes unnoticed. Mr. Carless tells me of a case recently seen by him
of a cleft of the soft palate in a child, whose mother, without asking
any leading questions, gave a history of a sharp attack of febrile
disturbance keeping her in bed two or three weeks at a period when the
fœtus could not have been more than two months old. This is the type
of maternal shock we should possibly look for, rather than the more
out-of-the-way maternal impressions commonly suggested.

The union of the parts entering into the formation of the palate,
alveolus, and lip is normally completed by the eighth to the tenth week,
and when once this has occurred in these parts no maternal impression
(such as seeing a gashed lip) could, as far as we know, bring about a
retrogressive change. Should some shock occur to the mother prior to that
period, we can fully appreciate the possibility of its interfering with
the typical growth of the parts then being produced; and the fact that
the due adjustment and union of so many component parts is requisite for
the normal development of the mouth and face explains why these defects
are relatively so common. That a severe shock to an infant may produce
coincidently a lamellar cataract and defective development of dentine is
well recognised; that a similar type of shock acting on the mother should
result in defective union of parts developing at that period in the fœtus
is not strange; but that the real shock and the so-called “Maternal
Impression” are one and the same is more than doubtful.




CHAPTER II.

ANATOMY AND PHYSIOLOGY OF THE NORMAL PALATE.

    _The hard palate—The velum and its muscles—The mucous
    membrane—The blood supply—The shape and size of the hard
    palate—Functions._


The palate is a more or less horizontal partition dividing the month from
the nasal cavity, and consists of a firm bony plate in front (the hard
palate) with a freely moveable membrano-muscular velum behind (the soft
palate), which under varying conditions of muscular action can either
open or close the communication between the nose and pharynx.

The bony palate forms the vaulted roof of the mouth, the central and
posterior parts of which are nearly horizontal; and on all sides, except
at the back, it is bounded by the alveolar ridge. Into its formation
several bones enter; in the adult skull one usually sees posteriorly a
cruciform suture indicating the limits of the superior maxillæ and palate
bones; but even in the adult, evidence is forthcoming in the existence
of traces of sutures to indicate that the anterior part of the palate is
formed independently of the part immediately behind it. Thus Mr. Carless
tells me that a cursory examination by him of a few dozen adult skulls
picked up at random in the Museum of the College of Surgeons revealed
the fact that in quite one half of them traces of sutures could be seen
extending outwards from the posterior part of the anterior palatine
canal; and a similar examination by him of 40 skulls from the Museum of
King’s College of many nations and various ages showed a similar result.
In almost all there was distinct evidence of the suture in the median
line; in 21, the maxillo-intermaxillary suture was indicated; whilst in
10 skulls, representing the period from infancy to young adult life,
both the above were seen in all, and 7 showed traces in addition of a
suture placed between them on either side, and which we shall describe
hereafter as the endo-mesognathic. Kölliker[34] similarly records that
out of 325 adult skulls examined, 96 of them showed definite traces
of the maxillo-intermaxillary suture. Albrecht[35] declares that nine
tenths of the skulls in the Königsberg and Kiel Museums from children
under five years of age reveal the existence of _five_ intermaxillary
sutures, proving that there are four separate portions to the so-called
intermaxilla. Each portion carries an incisor tooth, and the canine is
developed immediately at the junction between the outer portion and the
maxilla. Occasionally there are three incisors on each side, the jaw
being then called hexaprodontous; the extra tooth is developed from the
inner segment of the intermaxilla (or endognathion), the outer segment
(or mesognathion) carrying as usual only the lateral incisor. The
accompanying illustrations well indicate this arrangement of sutures and
teeth (Figs. 26 and 27); the importance of these facts will be emphasized
later. All traces of the facial aspect of these sutures disappear quite
early in life.

[Illustration: FIGS. 26 AND 27.—Diagrams to represent the normal human
upper jaw of a child, with four and six incisors respectively, and also
indicating the five intermaxillary sutures. (After _Albrecht_.)

EG, MG, XG. Endo-, meso-, and exo-gnathion. _e._ Inter-endognathic
suture. _f._ Endo-mesognathic suture. _g._ Exo-mesognathic suture. _i₁._
Central incisor. _i₂._ Lateral incisor. _iₐ._ Accessory incisor. _c._
Canine. _m₁._ First temporary molar. _m₂._ Second temporary molar.]

The bony surface of the roof of the mouth is perforated by numerous
small foramina for the transmission of the nutrient vessels to the body
of the bone, pitted for the lodgment of mucous glands, and grooved
longitudinally for the transit of vessels. At the postero-external
corners the posterior and accessory palatine canals give entrance to the
posterior palatine vessels, and nerves; and anteriorly in the median line
is the anterior palatine canal transmitting the naso-palatine vessels and
nerves.

The soft palate is a moveable curtain, consisting of a membranous
expansion or aponeurosis attached to the posterior extremity of the hard
palate by firm fibrous tissue. Incorporated with it are five pairs of
muscles, controlling its movements; it is covered by a smooth thin mucous
membrane, and terminates posteriorly in the uvula. The arrangement of
these muscles is important, not only from their normal physiological
functions, but also from their irregular action and effects in cases
of cleft palate (Fig. 28). They may be arranged in groups: two, the
levator and tensor palati, form a superior group; the azygos uvulæ is
intermediate; and the palato-glossus and palato-pharyngeus form an
inferior set. Arising from the extremity of the petrous bone, the levator
passes downwards, and spreading out below unites with its fellow in the
whole length of the median raphe. The tensor arises from the navicular
fossa of the internal pterygoid plate, and after being reflected around
the hamular process, its action there being assisted by the interposition
of a bursa, is attached to the anterior portion of the aponeurosis and
to the hinder part of the bony palate. The combined action of these
muscles raises and makes tense the velum, and in addition influences the
Eustachian tube; but the levator is by far the more important. The azygoi
uvulæ muscles arising from the median raphe and spine of the hard palate
descend to the tip of that process, and are thus able to regulate its
length.

[Illustration: FIG. 28.—Muscles of palate dissected. The cut represents
the posterior nares and upper surface of the soft palate.

_a._ The levator palati. _b._ The inner bundle of fibres of the
palato-pharyngeus, forming the posterior pillar of the fauces, _c._ The
palato-glossus. _d._ The tensor palati; the cartilaginous extremity of
the Eustachian tube is seen in front of this latter. _e._ The posterior
extremity of the inferior turbinated bone. _f._ The septum. _g g._ The
uvula on each side stretched apart. (_Fergusson._)]

The two descending muscles are placed in the pillars of the fauces,
forming the lateral prolongations of the velum, and the tonsils lie in
a recess between them. The palato-glossi arising from the tongue ascend
in the anterior pillars of the fauces, and spreading out on the anterior
surface of the velum unite in the median raphe. The palato-pharyngei
start from the median raphe in two lamellæ enclosing the termination of
the levator muscle; they descend in the posterior pillars of the fauces,
and being attached to the pharyngeal wall between the superior and middle
constrictors, by their contraction assist in raising the pharynx during
deglutition.

The nervous supply of these muscles requires little notice here; suffice
it that the superior set and the azygos are supplied by the facial nerve,
the inferior set from the pharyngeal plexus.

The _mucous membrane_ of the hard palate is of the usual oral type, and
only differs from that of the rest of the mouth in its close attachment
to the periosteum, from which in fact it is almost impossible to separate
it. It is thick, dense, rather pale and much corrugated, especially in
front and at the sides, whilst behind over the velum it is smoother and
thinner. In it are many small glands (palatine glands) which extend down
to the periosteum. In the median line is a well-marked raphe, extending
anteriorly to a prominence indicating the position of the anterior
palatine canal. The rugose condition of the membrane over the hard palate
is not seen in young children; it supervenes later in life.

The _vascular supply_ of the palate is free and abundant, a circumstance
which is of the greatest surgical importance in that it permits of the
free detachment of the soft structures from the hard by long lateral
incisions, and the necessary manipulation of these in uranoplastic
operations without any fear of loss of vitality, provided that the
patient’s health and constitution are tolerably sound, and that
sufficient pedicle is left in front and behind.

The mucous membrane of the hard palate derives its blood supply from
two of the terminal branches of the internal maxillary artery. The
naso-palatine descend through the anterior palatine canal, and entering
the palate at the incisive foramen (foramina of Stenson) assist in
supplying the anterior portion, anastomosing with the terminations of
the more important posterior or descending palatine, which find their
way to the palate from the spheno-maxillary fossæ through the posterior
palatine canals. Each of the latter arteries on reaching the palate
sends branches to the velum and tonsils, and its main twig runs onwards
in a groove of the bone to supply the mucous membrane and glands of the
hard palate and gums. Its usual position is parallel to the alveolar
border, and about three quarters of an inch from it; but this varies
considerably. The artery can often be felt pulsating as it emerges from
the bone, and is very likely to be divided in the lateral incisions made
during the operation of uranoplasty; but the knife should be carried
external to it, if possible, so that the trunk of the vessel may be
preserved in the flap. The bony palate derives its blood supply not only
from its lower surface but also from its upper, and hence detachment of
the inferior periosteal covering does not lead to death of the bone. The
soft palate derives its blood from three sources, viz. the ascending
palatine of the facial, the ascending pharyngeal, and the posterior
palatine of the internal maxillary. The two former reach it through
the sinus of Morgagni, _i. e._ over the upper border of the superior
constrictor muscle, forming loops of anastomosis on its posterior aspect
with similar branches on the opposite side; the last supplies the
anterior palatal surface.

The normal shape of the palate is a regular arch, bounded laterally by
the gums and alveoli into which the teeth are implanted so as to describe
a parabolic curve, being normally uninterrupted at any spot by spaces
or diastemata. The height and curvature of the palate vary considerably
in different individuals, not only from inherited peculiarities, but
also from acquired conditions dependent on the teeth. A person with a
good set of sound teeth will probably own a regular well-formed palate;
whilst if sundry of the upper permanent teeth are lost during the stage
of adolescence, the palate is likely to become high and narrow from the
falling in of the jaw. This is especially the case if the incisor teeth
are lost.

The shape of the palate in a child of two years does not differ so
markedly as one would at first expect from that of an adult except in
length, and the reason for this is plainly the existence in the latter of
three additional teeth on each side. Its increase in length is from 20
to 30 millimetres, whilst its breadth is only augmented by 10 to 15 mm.,
and this mainly posteriorly. When once the permanent incisors, canines,
and premolars are developed, the anterior portion of the palate alters
but little in shape, unless any of these teeth be lost, and the gaps not
artificially maintained.

Dr. Ehrmann[36] states that the alveolar border in front of the canine
teeth forms a nearly regular semicircle, with a posterior transverse
diameter of 22-26 mm.; thence the alveoli diverge regularly, adding
to the diameter about 2-4 mm. for each tooth. He gives the following
measurements as the mean of many observations:

                                |From 2-6 yrs.|From 7-10 yrs.|From 11 yrs.
  ------------------------------+-------------+--------------+------------
  Interval between canines      |22-25 mm.    |23-27 mm.     |25-28 mm.
  ------------------------------+-------------+--------------+------------
           ”       1st premolars|24-29 ”      |25-30 ”       |27-30 ”
  ------------------------------+-------------+--------------+------------
           ”       2nd     ”    |26-31 ”      |28-32 ”       |31-34 ”
  ------------------------------+-------------+--------------+------------
           ”       1st molars   |—            |—             |32-37 ”

Oakley Coles[37] has carefully investigated the size of the palate in
several series of skulls in the Museum of the College of Surgeons, and
gives the results as follows:

Of 34 adult skulls of European origin, the average length was 49 mm., the
average width at the second bicuspid was 35 mm., and the average height
from the margins of the alveoli 9 mm.

Of 32 adult skulls of mixed races, the average length was 54 mm., the
width 35 mm., and the height 12 mm.

The frequent association of inherited mental and nervous weakness with
a high arched palate is now a well-established clinical fact. Thus
Savage states that in “Genetous Idiocy” (_i. e._ idiocy which starts in
fœtal life, and cannot be traced to any specific disease) the palate is
usually keel-shaped, the molar teeth being closely approximated; they
are also late in appearing and deficient in number. “Although this kind
of palate may be present in healthy individuals or in those suffering
from ordinary insanity, if it be associated with weak-mindedness or moral
peculiarities in youth I believe one is justified in saying that the
tendency to moral or intellectual deficiency is congenital.”[38] Only
recently Dr. F. Warner has reported[39] to the Psychological Section of
the British Medical Association the results of an investigation as to the
occurrence of deformities amongst school children, and their relationship
to defective vital and mental conditions. Out of 5344 children examined,
physical deformity was noted in 399 cases, and of these 274 were boys
and 125 girls, _i. e._ in the proportion 9·8 per cent. and 5 per cent.
respectively. It was found that of these 25 per cent. exhibited evidences
of low nutrition, 36 per cent. evidences of nervous weakness, and 31
per cent. of mental dulness. 117 cases were noted of deformity of the
palate, 77 boys and 40 girls; and of these 35 per cent. gave signs of low
nutrition, 39 per cent. of nerve weakness, and 35 per cent. of mental
dulness. These defects were more marked and more frequent in the pauper
than in the elementary public schools, in the proportion of 4·2 to 2·2.
As to the character of the malformations, the following are the numerical
statistics: In 105 cases, the palate was arched, narrow, high or vaulted;
in 8, it was 𝖵-shaped; in 4 it was of the flat type.

Dr. Langdon Down[40] had previously noticed and pointed out this frequent
relationship, remarking that as the result of a large number of careful
measurements of the mouths of the congenitally feeble-minded and of
intelligent persons of the same age, he found with few exceptions a
marked diminution in the transverse measurement between the posterior
bicuspids, resulting in an inordinate vaulting of the palate. There
was often noticed an actual deficiency in the bony structures of the
posterior part of the hard palate, causing the velum to hang down
abnormally, interfering with phonation.

The _function_ of the hard palate is mainly mechanical. Acting as a
partition between the nasal and buccal cavities, it prevents nasal
mucus from falling into the mouth, and, by presenting an opposing
surface to the tongue, allows of the production by the latter of the
vacuum necessary for suction, and enables the tongue to direct the food
towards the alveoli, and to disintegrate soft particles, thus assisting
mastication. It is also an accessory to the development of taste by
enabling particles to be evenly spread over the back of the tongue. For
the production of articulate speech the hard palate is an indispensable
factor, and the quality of the voice is much influenced by its contour.

The functions of the soft palate are mainly related to the acts of
respiration, deglutition, phonation, and articulation.

1. _In respiration._—If the mouth is closed, and the respiration purely
nasal, the velum hangs loosely, and allows free passage of air through
the posterior nares. If the mouth is open, the velum is raised, and air
passes freely through the fauces to or from the larynx. When air passes
simultaneously through nose and mouth, the velum hangs in a more or less
flaccid condition midway between the two extremes, and sometimes, when
absolutely relaxed, vibrates, giving rise to snoring or stertor.

2. _In deglutition._—The passage of food into the nose is prevented by
the closure of the posterior nares. This is effected by elevation and
tension of the velum, the levator and tensor muscles acting in unison,
so that its position becomes almost horizontal. The raised velum meets
the posterior wall of the pharynx, which advances as the result of the
action of the upper horizontal fibres of the superior constrictor, and
the closure is completed on either side by the approximation towards
the median line of the posterior pillars of the fauces from the action
of the palato-pharyngei muscles contained therein. These, acting from
the soft palate as a fixed point, and raising the pharynx to grasp
the bolus of food, straighten the walls of the sphincter-like isthmus
faucium, and so guide the food as down an inclined plane. The tension of
the velum also assists in this guidance. That the above is the action
of the palatal structures is proved by the results of their imperfect
development or paralysis, _e. g._ in post-diphtheritic paralysis, where
the naso-pharyngeal cavities remaining unclosed, food (especially if
fluid) regurgitates into the nose.

3. _In phonation and articulation._—The soft palate is here of
considerable importance, inasmuch as it is needed to cut off the
naso-pharynx and nasal cavities from the oral pharynx. When defective
or paralysed, a certain amount of nasal resonance is imparted to the
voice, which, however, is less noticeable during vocalisation than
in articulation. For the production of clear normal voice-sounds it
is essential that the separation between nose and mouth should be
absolute, except for the sounds _m_, _n_, and _ng_. The American twang
is probably due to a slight relaxation of the soft palate, permitting
a small percentage of voice-sounds to pass through the nose. Dr. N. W.
Kingsley[41] has recently published some excellent diagrams illustrating
the position of these parts during the production of definite sounds, and
for all, except those mentioned above, the velum is horizontal, and in
contact with the posterior pharyngeal wall.




CHAPTER III.

DEVELOPMENT.[42]

    _Normal development of mouth, face, nose, and
    teeth—Ossification—Development of intermaxilla; old ideas
    (Goethe’s, &c.); Albrecht’s theory—Harelip; position of cleft
    in alveolus, and in lip—Dentition; accessory teeth—Development
    of other deformities._


Before discussing from an embryological standpoint the various
deformities which we have already described, it is essential for us to
consider the normal process of development of the parts entering into
their formation.

About the end of the third week of intra-uterine life, the anterior
cerebral vesicle becomes acutely bent over the end of the notochord, and
a marked depression is seen on the ventral aspect of this, constituting
what is known as the _Stomodæum_, or primary buccal cavity. This,
however, is formed rather by the outgrowth of surrounding processes
entering into the formation of the facial elements than by any definite
or distinct involution of epiblast. The cavity is bounded posteriorly
and superiorly by the cephalic flexure of the cerebral vesicles, and
inferiorly is separated from the cephalic portion of the intestine by a
septum. This becomes perforated at a slightly later date (eighth or ninth
week), and communication is thus established between the stomodæum and
intestine. Anteriorly, the opening is at first stellate in shape (Fig.
29), but soon assumes the form of a transverse cleft by the union in the
middle line of the first pair of post-oral branchial arches, in which
are developed the primary cartilaginous bars on either side, known as
Meckel’s cartilage, the anterior part of which goes to form the inferior
maxilla, and the posterior part the malleus. The soft parts around
develop into the lower portion of the cheek, the lower lip and chin (Fig.
30).

[Illustration: FIG. 29.—Head of fœtus, of about 5 weeks, from ventral
aspect (after His), showing the primitive stomodæum bounded above by the
undivided fronto-nasal process, laterally by the maxillary, and below by
the still separate mandibular processes. The quinqueradiate appearance is
well represented. (_Sutton._)]

[Illustration: FIG. 30.—Head of fœtus from ventral aspect of a little
later date (6-7 weeks). The mandibular processes have now united; the
orbito-nasal fissure has come in contact with the ocular vesicle, and the
fronto-nasal process has developed into external and internal nasal (or
globular) processes around the nasal fossæ (after His). (_Sutton._)]

At the same time that this mandibular arch is being developed, other
changes are occurring around the upper part of the stomodæum, viz. the
shutting off of sacs lined with epiblast to assist in the formation of
the organs of special sense, and the outgrowth between them of fleshy
processes which by their later amalgamation form the facial skeleton
and coverings. Three of these involutions of epiblast occur, two
communicating more or less with the stomodæum, viz. the nasal and ocular;
whilst the third, or auditory, is separate. Expansions from the cerebral
vesicles meet them, and by further changes, unnecessary to particularize
here, the organs of special sense are elaborated.

[Illustration: FIG. 31A.—Head of fœtus at a somewhat later date (8 weeks)
as seen from the front, showing the nasal and maxillary processes in
close apposition, and the clefts between them diminishing in size.

FIG. 31B.—The same, seen from below, the mandibular process having been
removed.

_i.m._ Central portion of fronto-nasal process, _m.n.pr._ Internal nasal
process. _pr.gl._ Globular process, or the lower rounded extremity of
the former. _l.n.pr._ External nasal process. _m.x._ Maxillary process.
_m.n._ Mandibular process.]

The most anterior of these depressions are the primary _Olfactory pits_
which appear on either side on the lower surface of the wall of the
anterior cerebral vesicle at a very early date. They are at first
merely depressions surrounded by a raised margin; but subsequently they
become pyriform by the extension of the lower end as a groove into the
stomodæum. Each pit and groove is bounded laterally by thickened rounded
outgrowths developed from a broad median fleshy protrusion from the same
part of the cerebral vesicle, the fronto-nasal process; these are termed
respectively the external and internal nasal processes, the latter being
also named by His the globular processes (Fig. 30).

These _Globular processes_ are separated in the median line by a groove
which is subsequently obliterated by their amalgamation to form the
central portion of the upper lip (“Philtrum” of German authors), and from
their deep aspect the inner segments of the intermaxilla (endognathia).
Above this groove is a central flattened median portion of the
fronto-nasal process, from which subsequently the prominence of the nose
is developed (Figs. 31A, 32, and 33), a result of the continued growth
from its deeper aspect of the ethmo-vomerine plate.

The _external nasal process_ forms the ala nasi and the soft parts in
its immediate neighbourhood, extending downwards a little distance, but
probably not so far as the red margin of the lip. From its deeper aspect
the outer portion of the intermaxilla (mesognathion) is developed, and in
it appears the germ of the lateral incisor. It also serves to separate
the nasal pit from the second epiblastic intrusion which assists in the
formation of the eye. The lower boundary of the naso-orbital fissure
which passes from the primary ocular involution to the stomodæum is
formed by the _maxillary process_, which is usually described as an
upward extension of the mandibular process, but which probably arises
separately as a pre-oral branchial outgrowth. From this is developed
the whole of the superior maxilla, except that portion which is
intermaxillary, and also the greater part of the cheek.

[Illustration: FIGS. 32 AND 33.—Later stages of development of fœtal
head.]

About the sixth week the stomodæum shows signs of division into upper and
lower segments by the outgrowth from the deep aspect of each maxillary
process of horizontal _palatal plates_, which by their junction in the
median line form the rudiments of the hard and soft palate, separating
thus the nasal and buccal cavities. The anterior portion of these unite
with the lateral aspects of the deeper parts of the fronto-nasal process,
leaving a space of greater or less dimensions in the median line, known
as the anterior palatine canal, which serves subsequently for the passage
of nerves and vessels, and for the lodgment of the “organ of Jacobson” in
animals in which it occurs.

The upper or nasal cavity is again subdivided into lateral halves by the
growth downwards from the under surface of the fronto-nasal process of a
central vertical septum, to become in time the cartilaginous septum nasi
and the bony ethmo-vomerine plate, uniting at its lower border with the
primary fleshy palatine processes (Fig. 34).

The tongue grows as a fleshy protuberance from the floor of the
stomodæum; antero-lateral segments on either side from the conjoined
second and third branchial arches unite with a central posterior growth
from the tuberculum impar in an inverted 𝖸-shaped manner. At the point
of junction of the segments is a depression from which the thyroid gland
develops, indicated in later life by the foramen cæcum.

[Illustration: FIG. 34.—Diagrammatic representation of the development of
the palatal processes and of the ethmo-vomerine plate, seen in vertical
section. (After _Gegenbaur_.)

_a._ Ethmo-vomerine plate. _b._ Palate processes. _c._ Tongue. _d._
Buccal cavity. _e._ Nasal cavity.]

Each of these primary epiblastic pits is at a later date almost entirely
cut off from its connection with the buccal cavity. The external and
internal nasal processes of the fronto-nasal outgrowth unite below the
anterior olfactory pits, and thus surround the anterior nasal apertures,
and separate the nares from the mouth. The external nasal and superior
maxillary processes are also freely amalgamated except along one small
deep track, which remains patent to form the nasal duct and lachrymal
passages; and probably the internal nasal and maxillary processes unite
below the external nasal process to establish the continuity of the
red margin of the upper lip. The union of all these various parts has
been completed by the sixth to the tenth week of normal fœtal life; the
external nasal and superior maxillary processes unite first, and by the
sixth week are becoming closely approximated to the central portion of
the fronto-nasal process, a time when the palatal processes are only
indicated as slight ridges. By the ninth week the alveolus and upper
lip are complete, and union of the palate is commencing from before
backwards, being usually completed even to an indication of the uvula by
the tenth week.

Whilst the later stages of these developmental processes are in progress,
points of _ossification_ have been appearing in many places to form
the cranial and facial skeleton. A full knowledge of this subject is
still unattained, but the researches of Goodsir, His, and others have
thrown much light on hitherto dark passages. There are two main sources
of origin of the bones of the skull, viz. from cartilage and from
membrane, and it is important to appreciate the portions of the skull
which originate from each of these sources respectively. The bones laid
down primarily in cartilage are mainly those forming the base of the
skull and their anterior prolongations. Thus about the fourth week of
intra-uterine life the basis cranii consists of a cartilaginous mass
surrounding the upper end of the notochord, and prolonged anteriorly
around the pituitary fossa as two cartilaginous bars, the _trabeculæ
cranii_, into the fronto-nasal process. From the anterior extremity of
this the nasal bones and cartilages are developed, and from the under
surface the ethmo-vomerine plate. The transformation of the primordial
mesoblastic undifferentiated tissue into recognisable cartilage is
occurring from about the fourth or fifth week until the eighth, when
ossification at different centres is apparent. To the development of the
intermaxilla we shall refer in detail later; suffice it to say here that
the ossifying centres appear about the eighth week, and by the twelfth
to the fourteenth the whole process is ossified, and the space between
the maxillæ closed except posteriorly, where the anterior palatine canal
remains permanently patent; the component parts of the bone, however,
are not united until a later date. There are two other cartilaginous
foci from which ossification ensues, viz. the pterygo-palatine cartilage
in the superior maxillary process, a delicate bar from which arise in
part the pterygoid and palatine plates; and Meckel’s cartilage in the
mandibular process for the production of the mandible and malleus. All
the other facial bones are developed from membrane, more or less in
connection with these bars. The vomer is ossified from a single nucleus
appearing in the upper part of the ethmo-vomerine plate, about the ninth
week; from this two laminæ are developed, which, passing downwards and
forwards on either side of the middle line, embrace the septal cartilage.
The amount of the osseous material increases from behind forwards,
until at maturity a median osseous lamina remains which is grooved only
anteriorly.

The palate bone develops from a single centre appearing about the eighth
week at the junction of the horizontal and perpendicular portions.
The superior maxilla is supposed to arise from four separate foci of
ossification, viz. for the alveolar arch, for the palate, for the
orbito-malar portion, and for the naso-facial segment. All these are
united together by the third month.

It is unnecessary here to discuss the development of the _teeth_ beyond
stating that the thickening of the epiblast covering the gums, which
occurs as the earliest sign of the production of the milk teeth, is to
be seen about the forty-fifth day, when as yet there are no signs of
ossification of the maxilla, and by two and a half months a distinct
involution filled with cells is evident. Calcification commences about
the eighteenth week of intra-uterine life, and extending from crown to
fang is usually not completed until from twelve to twenty months after
birth.

By the fifteenth week of embryonic life preparation is being made for
the development of the first four permanent molars, and soon afterwards
in the sixteenth week occur the inflections of the mucous membrane
giving rise to the enamel organs for the twenty anterior permanent
teeth; and from this period until the birth of the infant the germs of
the twenty-four permanent teeth are passing through the various stages
preparatory to calcification, so that at birth the child has not only
twenty milk teeth with calcification nearly complete, but also the germs
of twenty-four permanent teeth. Calcification commences in twelve of
these latter during the first year of life, viz. in the first molars and
the incisors, and spreads from the crown in which it starts to the fang.
In the case of the incisors this process is not completed until the tenth
year.[43]

       *       *       *       *       *

The question as to the ossification of the intermaxilla has been
purposely omitted hitherto, that the subject and its morphological
relationship to congenital deformities might be more fully discussed.

In the time of Galen[44] the presence of the intermaxilla as a separate
bone had been demonstrated in apes and lower animals, and its existence
in man inferred, although probably not actually seen. This opinion
held its ground till the sixteenth century, when Vesalius attacked
it, maintaining that no such bone existed in man, and its absence was
even claimed as a distinguishing feature from the lower animals. The
first to actually discover and notify the separate existence of the
bone in the human skull was Dr. Robert Nesbitt,[45] who, in a lecture
before the Royal College of Surgeons in 1736, described and figured
the suture crossing the anterior part of the palate at all times of
life, and maintained that during intra-uterine life each superior
maxilla “is generally divided into two distinct parts, the sutural line
running from between the dentes canini and incisivi up to the bottom of
the nose.” But the merit of appreciating the importance of this fact
belongs to Goethe[46] and Vicq d’Azyr,[47] the former of whom, in the
year 1779, demonstrated the existence of the intermaxilla in the human
fœtus, and, as the outcome of this discovery, promulgated in 1819 the
theory that in alveolar harelip the cleft in the alveolus occurs at the
maxillo-intermaxillary suture, _i. e._ between the lateral incisor tooth
and the canine. This opinion has been believed and handed down through
successive generations of surgeons until the present day, but more recent
and exact research has so increased our knowledge that it cannot now be
considered correct. Many painstaking embryologists have, during the last
ten years, been investigating this subject; but the honour of raising
the question as to the morphological position of the cleft in harelip
lies with Professor Albrecht of Brussels, who in a masterly series of
papers has fully established the fact, observed also by others, that
the intermaxilla is not developed _en masse_, but is formed by the
coalescence of _four_ segments, two on either side; and he maintains
that the cleft in alveolar harelip lies not between the maxilla and
intermaxilla, but between the inner and outer intermaxillary segments.
These have been named respectively the endo- and meso-gnathion, whilst
the maxilla proper is called the exognathion. According to Albrecht,
therefore, the cleft is not situated along the exo-mesognathic, but
along the endo-mesognathic suture.

Much controversy has been lighted up by this pronouncement, but here only
a few of the points of interest and importance will be discussed.

The development of the intermaxilla from two centres on each side may
be accepted as a proven fact. It was first maintained by the late Mr.
Callender,[48] who stated that these bones have a lateral wedge-shaped
sutural surface, fitting into a groove in either superior maxilla, and
that the alveolar processes of the latter extend forwards, forming the
anterior walls of the sockets of the central incisors, and so fix the
bones in position. A confirmation of the idea that the anterior alveolar
walls of the incisor teeth are formed in this way was sought in the
well-established fact that these particular parts are very imperfectly
developed in those cases of alveolar harelip in which the os incisivum
is isolated from the superior maxillæ; but such is probably due to the
abnormal condition and position in which the bone is developed, rather
than to the loss of the maxillary “clip.” And certainly the most recent
researches tend to prove that the maxillæ have no share in the formation
of the alveoli of the incisor teeth.

Sir William Turner and other anatomists have fully confirmed this method
of development from four ossific centres, and important additions to
our knowledge of the subject have been made recently. Thus M. Gilis[49]
describes and figures the condition of the palate as seen in a six-months
fœtus, where it was clearly demonstrated that the intermaxillary portion
formed a sort of lozenge-shaped prism fitting in between the two maxillæ,
and consisting of four portions of bone, the sutures between these being
perfectly clear and distinct (Fig. 35). The posterior extremity of the
short axis of the intermaxillary segment corresponds to the anterior
palatine canal, and the anterior surface forms the median anterior
alveolar border, no process of the superior maxilla closing in the
alveoli in front. The upper border of the bone forms the floor of the
nasal apertures.

[Illustration: FIG. 35.—Bony palate of a fœtus of six months, showing the
development of the intermaxilla in four portions.

_a._ Endognathion. _b._ Mesognathion. _c._ Exognathion. _d._ Anterior
palatine canal. _e._ Endo-mesognathic suture.[50] _f._ Exo-mesognathic
suture. (After _Gilis_.)]

Biondi, of Breslau,[51] has completed the observations necessary for
the establishment of this fact by demonstrating the four actual points
of ossification in many fœtal skulls of different dates, which had been
specially prepared for the purpose. Moreover, as mentioned before (p.
27), traces of the five intermaxillary sutures, when looked for, may be
found in many adult and in the majority of young skulls.

The fourfold division of the intermaxilla being granted, it is obvious
that a cleft through the alveolus such as that occurring in alveolar
harelip happens at one of the two following situations, either along the
endo-mesognathic, or through the exo-mesognathic suture, _i. e._ between
the component elements of the intermaxilla, as Albrecht declares, or
between the maxilla and intermaxilla, as Goethe suggested—a claim which
has been vigorously defended by Kölliker against its newer rival.

The relative position of the clefts is indicated in the diagrams appended
(Figs. 36, 37, and 38).

[Illustration: FIG. 36.—Diagram representing the old or “Goethe” theory
of alveolar harelip, indicating both central and lateral incisors as
developed from one intermaxilla on either side, and the alveolar cleft
between the maxilla and intermaxilla.

M. Maxilla. IM. Intermaxilla. _i₁._ Central incisor. _i₂._ Lateral
incisor. _c._ Canine. _m₁._ First molar. _m₂._ Second molar.]

[Illustration: FIGS. 37 AND 38.—Diagrams to represent the “Albrecht”
theory of harelip, in conditions where the alveolus contained four or six
incisors respectively.

EG. Endognathion. MG. Mesognathion. XG. Exognathion. _i₁._ Central
incisor. _iₐ._ Accessory incisor. _i₂._ Lateral incisor. _c._ Canine.
_m₁, m₂._ 1st and 2nd molars.]

Albrecht’s papers on the subject are numerous, and contain a large amount
of interesting material which space forbids us to introduce here; and
one must refer readers, desirous of knowing more, to the appended list
of his chief works.[52] But the arguments in favour of his theory may be
briefly stated to be drawn from the following facts:

[Illustration: FIG. 39.—Drawing of an adult upper jaw with right-sided
alveolar harelip and cleft palate, and the vomer attached to the left
palatal margin. A rudimentary mesognathion bearing the stunted lateral
incisor is shown on the outer side of the cleft.

_i₁, i₂._ Central and lateral incisors, _x._ Inter-endognathic suture.
_y._ Exo-mesognathic suture. (After _Albrecht_.)]

1. That in cases of alveolar harelip, a small portion of bone has been
found in many instances on the outer side of the cleft, quite distinct
from the maxilla. This is claimed to be the mesognathion, separated
by the cleft from the endognathion, and by a distinct suture from the
exognathion. A picture (Fig. 39) is appended of an adult skull taken
from the museum of the Royal Anatomical Institute of Kiel, which clearly
shows a small distinct flake of bone in the required position, extending
back as far as the ordinary site of the anterior palatine canal. Such
has been also found in children’s skulls, and very distinctly in a
series of horses’ skulls with alveolar harelip. (For figures of such,
_v._ ‘Langenbeck’s Archiv,’ xxxi, 2.) But this condition, indicating
the distinct entity of the mesognathion, is not very commonly to be
demonstrated in human pathology, inasmuch as the suture is early
obliterated. But its existence is indicated by the dentition, to which we
must now turn.

[Illustration: FIG. 40.—Drawing of a case of double alveolar and palatine
cleft with projecting os incisivum, to show the lateral incisor on outer
side of the cleft.

_i₁_, _i₂_, _c_, _m₁_, _m_₂, represent the alveoli of the teeth as in
Figs. 26 and 27. _v._ Vomer. B. Palatal process of superior maxilla
united to the meso- and exo-gnathion. A. Os incisivum, consisting of the
two endognathia, and bearing the alveoli of the central incisors. (After
_Albrecht_.)]

2. That in alveolar harelip there is in a large number of cases a
distinct precanine or incisor on the outer side of the cleft. This
is well shown in Figs. 39 and 40. In the former, an adult skull, the
mesognathion is distinctly seen bearing the alveolus of a precanine
tooth, the lateral incisor; whilst the central bony portion (the
endognathion) bears but the socket for one tooth, the central incisor.
The latter is a picture of a child’s skull with double alveolar harelip
and cleft palate; the os incisivum is seen separate and projecting
forwards at the end of the nasal septum; it bears the sockets of the two
central incisors. Outside the cleft the alveolus bears four teeth on
either side, viz. two molars, one canine, and one precanine, which we
cannot but recognise as the normal lateral incisor. So that the dental
formula of the upper jaw might be represented thus:

                        In normal jaw—CI₂I₁I₁I₂C;

in double alveolar harelip—

                              CI₂=I₁I₁=I₂C,

where C represents the canine, I₁ and I₂ the central and lateral
incisors, and the double lines indicate the position of the clefts.
Careful examination of a considerable number of skulls has brought
much confirmatory evidence to light, indicating the truth of the above
proposition. Thus, to pick out a few facts from the mass of material
available:—Sabourand[53] records two cases of unilateral harelip with
cleft palate, one of which died at the age of thirty-three days. In
each the dentition was typically that described by Albrecht, viz.
four teeth on the side of the cleft (two molar, one canine, and one
precanine), and six on the opposite (two median incisors, one lateral
incisor, one canine, and two molars). Broca[54] has reported a case
of a much deformed fœtus stillborn at seven months. In this there was
cleft palate and double harelip with the os incisivum freely moveable,
but not displaced. The bone was found to consist of two little masses,
mobile on each other, and each containing two incisor germs; and on each
side external to the cleft there was a precanine similar in shape to the
incisors. The middle one of these three incisors was distinctly the least
developed.

Again, Sir William Turner[55] has carefully investigated the dentition,
as seen in casts obtained from various hospitals, of fifteen specimens
of alveolar harelip, eight of which were single left-sided, four single
right-sided, and three double clefts. To these he adds the records of
forty-nine preparations examined and reported on by Kölliker;[56] we can
here, therefore, discuss the dentition of sixty-four cases. They may be
divided into two groups:

(α) In which no precanine intervened between the cleft and the
canine—thirteen cases.

(β) In which a precanine existed between the cleft and the
canine—fifty-one cases.

In not a few instances the os incisivum contained four teeth, and yet a
precanine existed external to the cleft, _i. e._ in hexaprodontous jaws
the cleft passed between the middle and outer precanines.

A similar condition is described by Albrecht[57] as occurring in an adult
human skull in the museum of the University of Kiel. In this a cleft
palate exists, with the fissure extending through the alveolus of the
right side, _i. e._ a right-sided alveolar harelip with cleft palate. The
mesognathion is plainly seen on the outer side of the cleft, bearing an
incisor tooth. On the inner side of the cleft (_i. e._ on the left side)
are the alveoli for five incisors before reaching the canine socket of
the left side, so that here is a skull with six incisor teeth, and with a
cleft between the alveoli of the right middle and outer precanines. And
not a few similar preparations are indicated by Biondi[58] as occurring
in the Berlin and Breslau collections. The condition of parts is
represented diagrammatically in Fig. 38. Albrecht’s explanation is that
the middle of the three precanines, _i. e._ the outer tooth in the os
incisivum, is an accessory development; whilst that on the outer side of
the cleft is the normal lateral incisor springing from the mesognathion.

With such facts one necessarily collates the accredited teaching
respecting the number and character of the incisor teeth in man.

Normally one finds two incisors on each side, occupying the space between
the canines, but it is a fact perfectly well recognised by dentists that
occasionally an extra precanine or incisor is present (Fig. 27); and very
rarely are there more than three incisors on either side. My colleague,
Professor Underwood, tells me that once he has seen the cast of a jaw
with at least five precanine teeth on one side only, but that was an
absolute exception, and only to be explained as a vagary of nature. The
more common existence of three incisors can scarcely be placed in the
same category, especially when one considers that although not constant
by any means throughout the series, yet amongst the mammalia one does
find three incisors as an oft-repeated formula; and certainly the typical
mammalian dental formula would indicate the occurrence of three incisors
on each side. Hence it is possible that the occasional occurrence of
three incisors in man is an illustration of the so-called “recurrence
to type,” and that, under ordinary circumstances, one incisor has been
suppressed; and the majority of anatomists fully concur in the belief
that it is the middle one of the three which has disappeared. The
occasional failure of the wisdom teeth to erupt, an occurrence which
dentists tell us is increasing in frequency, is additional evidence as to
the possibility of the disappearance of an incisor.

The accessory tooth in the os incisivum met with in some cases of
alveolar harelip is maintained by Albrecht to be a reappearance of this
lost middle incisor; and his explanation of such an occurrence seems very
feasible, viz. that the existence of the alveolar cleft prevents the
naso-palatine artery from anastomosing with the posterior palatine, and
thus the vascular supply to the os incisivum is greater than it should
be under normal circumstances; hence, there being a superabundance of
nutrient material, nature uses such in the restoration of a structural
unit ordinarily suppressed. The same fact (viz. the absence of the usual
anastomosis) may explain why the mesognathion is (even when demonstrably
present) always small and the lateral incisor not infrequently stunted or
absent, and so answers the objection to this theory which has been raised
on the ground that in cases of alveolar harelip an incisor external to
the cleft is not invariably present.

Hence the dental formula in cases of alveolar harelip will vary as
follows:

In tetraprodontous jaws—

                              CI₂=I₁I₁=I₂C,

or

                                C=I₁I₁=C;

in hexaprodontous jaws—

                            CI₂=IₐI₁I₁Iₐ=I₂C,

or

                              C=IₐI₁I₁Iₐ=C,

where Iₐ represents the accessory incisor, the other letters as on p. 51.
The former of each of these pairs of formulæ represent the mesognathion
and lateral incisor as present, the latter as absent.[59]

Notwithstanding the mass of positive evidence which is steadily
accumulating in favour of Albrecht’s theory, there are still some careful
observers who will not admit its truth. Some attack it on the ground that
the intermaxilla does not consist of four portions (Kölliker, &c.); with
such we have already dealt. Others object to it on the ground that any
teeth existing external to the cleft are merely accessory teeth, or due
to a bifidity of the canine. The arguments with which they support their
opinion are derived from the following considerations:

(i) That in normal development accessory teeth do certainly occur,
as in the case mentioned above (p. 53), whilst in a few instances of
abnormality the same condition has been noted (_e. g._ a few cases
recorded by Kölliker;[60] see also Fig. 19, showing a facial cleft in
which several accessory teeth are present along the inner margin). And
the explanation given of such facts is that the involution of mucous
membrane from which the teeth are developed is continuous along the
alveolar ridge, and not localised to the definite spots from which the
teeth subsequently erupt. This, however, is merely an opinion still _sub
judice_, and not absolutely proven.

(ii) That in other defects accessory structures are sometimes produced
in the neighbourhood, as if Nature, being baulked in her efforts of
development at one spot, expends her energies in some less useful
addition elsewhere. The accessory auricles and auricular appendages seen
in macrostoma are cited as illustrations of this; and any precanine
external to the cleft is maintained to be of a similar character. Whilst
fully admitting the plausibility of such teaching, I cannot see that it
explains such osseous development as occurs in Albrecht’s Kiel skulls,
or such a regular appearance of an incisor external to the cleft as that
indicated by the figures quoted above. The less frequent existence of an
accessory tooth in the os incisivum seems much more readily explicable on
such a ground.

       *       *       *       *       *

To summarize the principal points as to the development of ordinary
harelip:

1. That the intermaxilla is derived from the union of four ossific
portions, two on either side of the median line, and that these are to be
known respectively as the endo- and meso-gnathion, whilst the superior
maxilla is termed the exognathion.

2. That these ossific portions are developed from the internal and
external nasal projections of the fronto-nasal process respectively, and
that ordinarily the central and lateral incisors are developed one from
each segment. Occasionally an accessory incisor is developed between the
other two from the endognathion.

3. That the external nasal process does not enter into the formation of
the upper lip, but terminates superficially in the depression immediately
below the ala nasi (see p. 57).

4. That simple harelip, where the cleft is limited to the soft parts,
is due to the non-union of the superficial portions entering into the
formation of the lip.

5. That in alveolar harelip the cleft passes between the endo- and
meso-gnathion.

6. That the os incisivum consists merely of the two united endognathia,
and normally carries only the two central incisors. Any additional tooth
is not the normal lateral incisor, but an accessory one, probably due to
the reappearance of an old suppressed member.

7. That any precanine existing on the outer side of the cleft is the
normal lateral incisor, springing from the mesognathion; but that the
latter portion of bone is rarely seen as a separate entity in human
skulls possessing such deformity, from early obliteration of the suture
between it and the maxilla, and that it is often badly developed and the
lateral incisor stunted or undeveloped from defective vascular supply.

       *       *       *       *       *

Having entered thus fully upon the question as to the situation of the
cleft in alveolar harelip, we must now turn to the consideration of
the morphological position of the oblique _facial clefts_, and their
relations to the above.

It has been already pointed out that they commence at about the same
spot in the lip margin as ordinary harelip, and thence run upwards and
outwards clear of the ala nasi towards the centre of lower eyelid,
following along the line of the naso-orbital fissure. Such a condition,
coupled with the developmental facts already mentioned, viz. the
existence of four segments in the intermaxilla and their relations to the
internal and external nasal processes, suggests the following conclusions:

1. That the situation of the cleft in the lip margin is in all
probability between the internal nasal and maxillary processes. The
truth of this proposition depends on whether or not the external nasal
process has any share in the formation of the lip. His, in his diagrams
(Fig. 30), seems to indicate that it does not, whilst Biondi[61] claims
that it does. The fact that these facial clefts commence at about the
same spot in the lip margin as do the clefts in harelip seems distinctly
to point to the conclusion that the superficial portion of the external
nasal process is limited to the development of the ala nasi, and of the
soft parts immediately around it. And this opinion goes far to explain
the dimpling of the skin around and the consequent definition of the ala
nasi.

2. That the situation of the cleft in the alveolus is between the
meso- and exo-gnathion, so that the first tooth on the outer side, if
developed, will be the canine.

3. That the upper extremity of the cleft should typically be located at
either the inner canthus or about the middle of the lower eyelid; but
this is not always the case. The association with coloboma iridis is
readily explained by an imperfect closure of the choroidal cleft which
normally occurs at the lower and inner segment of the globe.

_Median harelip_ in its two forms is readily explained. The true
median cleft is due to the non-union of the two globular processes
developed from the median portion of the fronto-nasal outgrowth. If
prolonged between the bones, it occupies the position of the median
inter-intermaxillary suture, and so passes between the two endognathia.

The more serious and complete form is due to the non-development of the
globular processes, and hence absence of the central portion of the lip,
the endognathia, and of the ethmo-vomerine plate. The contour and size
of the alæ nasi in pictures of this deformity suggest strongly that the
external nasal processes are developed, but no record of the dentition of
these rare cases is to be found.

_Macrostoma_ is due to the non-union of the maxillary and mandibular
processes, or possibly in some instances to the imperfect development of
the former.

_Mandibular clefts_ are due to the non-union of the separately developed
lateral segments of the mandibular process—a deformity which must result
from an earlier interference with the normal conditions of development
than any of the others. Prof. Wölfler has pointed out that at the period
when the branchial arches are being formed, the aortic bulb lies between
their ventral extremities, reaching up even as high as the mandibular
processes. If from any cause the retrogression of the heart and aortic
bulb into the thorax is interfered with, then non-union of the visceral
arches may result, and even a cleft mandible may thus be caused. This
ingenious theory is stated only to apply to the more severe cases.[62]

_Cleft palate_ is due to non-union of the palatal outgrowths of the
maxillary processes. When the cleft extends beyond the anterior palatine
canal it may pass along any of the intermaxillary sutures, but usually
between the endo- and meso-gnathion on one or both sides. Inasmuch as the
palate closes normally from before backwards, it is most common to find
the deficiencies at the posterior rather than at the anterior end.




CHAPTER IV.

THE ANATOMY AND PHYSIOLOGY OF HARELIP AND CLEFT PALATE.

    _Harelip—Effect of labial muscles on deformity—Structure of os
    incisivum and labial segments._

    _Cleft palate—Arrangement and action of muscles—Shape
    of bony segments—Associated irregularity in shape of
    skull—Physiological effects in nutrition, articulation, &c._


The short description of these congenital conditions given in Chapter
I must be now supplemented by a little more exact account from an
anatomico-physiological point of view.

With regard to harelip, if unilateral, but little remains to be said,
except to emphasize the fact that the deformity is not altogether due to
loss of substance, but to a considerable extent to the unbalanced action
of muscles, the equilibrium of which has been disturbed by the fissure.
Thus the orbicularis oris, which should have a sphincter-like action, has
its continuity interrupted, so that when contraction occurs, the effect
will be to widen and evert the edges of the cleft. The muscles acting
upon the corners of the mouth, moreover, will tend to exaggerate the
deformity, and thus all such actions as laughing and crying will have a
similar result.

The margins of the cleft are rounded, and the red mucous border of the
lip passes up for a variable distance on either side, but does not extend
to the apex except in very slight fissures. The upper part of the cleft
in the more serious forms has its margin formed of skin, a fact which
must not be overlooked in planning an operation for its cure, and which
will be again alluded to in the next chapter.

The space between the segments of the lip is usually triangular in shape,
and like an inverted V; it may or may not communicate with the nostril.
In alveolar harelip the alveolus is cleft, as has been already described,
along the endo-mesognathic suture; but the floor of the nose is not
necessarily implicated.

The line of fissure in many instances passes through the maxillary
attachment of the depressor alæ nasi, and the absence of the controlling
influence of this muscle is an important element in the production of the
broad flattened condition of nostril such a common accompaniment of this
deformity, thus affording an explanation of the nasal distortion in cases
where the alveolus is intact. If that structure be also implicated, then
the floor of the nose will be deficient to a greater or less extent, and
the tendency of the nostril to fall away increased.

On raising or making tense either segment of the cleft lip, the existence
of strong reflections of the mucous membrane or frænula will become
evident, in addition to the normal mesial frænum; these are sufficiently
firm to limit the range but not to antagonise completely the action of
the muscular contractions already alluded to. Moreover, unless freely
divided by undercutting they will effectually prevent by their tension
the parts being brought into a state of easy apposition, so necessary in
order to gain primary union.

In bilateral or double harelip the maxillary segments on either side
correspond in every particular with the outer segment in a unilateral
cleft; but the central portion which is continuous with the columna
nasi deserves special notice. It is usually ovoid in shape and stunted,
appearing as if shrunken upwards from the absence of lateral support;
its breadth and length are nearly equal, and there is a small portion
of the red labial margin at the lower part. It is attached on its
deep aspect to the os incisivum by firm muco-fibrous frænula, and in
aggravated cases it appears to project amalgamated with the columna
from the tip of the nose, forming the proboscis-like appendage already
illustrated (Fig. 8).

[Illustration: FIG. 41.—Os incisivum, consisting of two lateral bony
segments, each bearing an incisor. (_Fergusson._)]

The os incisivum has usually a larger superficial area than this
“philtrum” of the upper lip, and hence protrudes beyond it in all
directions. It forms a projecting tubercle, covered by smooth mucous
membrane on its under side, with the central portion of the upper lip
attached anteriorly. In a young child it consists of two little portions
of bone, imperfectly united together, which in the fœtus are represented
by two cartilaginous nodules, mobile on each other, and within each
a separate ossific centre; in other words, it is formed by the two
endognathia. Inside are found the rudiments of a variable number of
teeth; ordinarily in a child’s os incisivum, operated on at the usual age
(viz. one to three months), one finds on laying it open the rudiments of
four teeth, the temporary and permanent central incisors, arranged in
pairs, one above the other. Occasionally, as has been already mentioned
(p. 54), one finds evidence of the development of another incisor on one
or both sides of the projecting tubercle, and directed towards the cleft;
but such is usually imperfectly developed and stunted. In fact, amongst
all the ossa incisiva removed by Sir William Fergusson and now preserved
in King’s College Museum, but few show any traces of the additional
incisor, whilst the common arrangement is to find only the two central
teeth (Fig. 41). In no case is there any evidence of the existence of
more than two bony segments.

The anterior wall of the bone is always badly developed, and most
commonly when displaced the growth of the whole projection is somewhat
impeded, so that it is smaller than in the normal condition.

Its position may vary, being occasionally but little displaced
anteriorly, though in consequence of its slight basis of support, viz.
the antero-inferior extremity of the vomer, it is generally mobile; bands
of muco-fibrous tissue are occasionally seen passing from it to the
maxilla under such circumstances. Every variety of anterior displacement
is met with, until the severest forms alluded to above are reached. If
operative interference be delayed until late in life, the vomer becomes
dense and hypertrophied, and the junction with the os incisivum much
firmer, increasing the subsequent difficulties and dangers of treatment.
More exact details as to the dentition in cases of alveolar harelip have
been already given and discussed in a former chapter (p. 51). It is
interesting to note here, however, that the temporary incisors, both in
the intermaxilla and lower jaw, have a tendency to appear earlier than
usual; I have many times seen incisors in such cases erupted at birth.

       *       *       *       *       *

Amongst the many contributions to surgery which we owe to the late Sir
William Fergusson, not the least is that interesting account given of
the anatomy of cleft palate, derived from a minute dissection of a case
which came under his observation in the dissecting room. The specimen
was obtained from the mouth of an aged female.[63] The fissure in this
case was one of medium severity, implicating the velum and the posterior
portion of the hard palate. The upper horizontal fibres of the superior
constrictor were more fully developed than under ordinary circumstances,
and would appear to have assisted in shutting off the posterior nares
during deglutition and speech. The tensor and levator palati muscles were
normally situated and developed, and it appeared from this dissection
that the latter muscle was the main factor in drawing the velum upwards
and outwards. Consequently the division of this muscle in some way or
other is absolutely essential where any plastic operation is undertaken
for the closure of the cleft. The palato-glossi and palato-pharyngei
evidently possess the power of drawing the posterior part of the velum
outwards and downwards, but they are by no means so powerful as the
levator.

During muscular repose the edges of the cleft are considerably
approximated to one another; indeed, the posterior halves of the velum
may even touch, and the same condition to a limited degree obtains
during deglutition. Fergusson rightly ascribed the latter effect to the
contraction of the upper portion of the superior constrictor, which we
have already mentioned is hypertrophied, the levator and tensor muscles
being at the same time presumably relaxed. If the edges of the cleft be
irritated, the lateral segment is instantly drawn upwards and outwards,
and disappears as it were, an observation which emphasizes the necessity
for the complete division of the levatores at some period of the
operation.

Where the cleft extends into the bony palate, it is not uncommon to find
the pitch of the palatal segments vary considerably. If the cleft be
incomplete, the sides will be regularly sloped, although the vault may be
higher than usual; whilst in cases of complete cleft, it is not uncommon
to see an excessive upward slope of the bones like a Gothic arch, but not
always symmetrical. Pollock states that “the more complete the cleft, the
nearer the perpendicular are the sides of the palate;” and consequently
when the soft tissues are detached from the bone in uranoplasty the
flaps will fall into position more readily, and in many cases meet
without difficulty in the median line. The following diagrams (Figs. 42
and 43) indicate how much more advantageous such a condition is than when
the palatal segments approach more nearly the horizontal.

[Illustration: FIGS. 42 AND 43.—Diagrams representing the greater
facility for bringing the muco-periosteal flaps together when the palatal
segments are vertical rather than horizontal. (_Mason._)

A B. Bony palatal segments.

A C. Muco-periosteal flaps.]

My friend Mr. Oakley Coles has in his book on ‘Deformities of the
Mouth’[64] gone very fully into the question of the association of
abnormalities in the shape of the cranium with deformities of the palate,
endeavouring to prove that the palatal defect is concurrent with, if
not dependent upon, a non-development of the left lower parietal region
of the cranium, _i. e._ of the portion of the skull overlying Broca’s
convolution, which governs the function of articulate speech. Into this
question space forbids me to enter here, and I would refer my readers to
his excellent book, merely quoting some of the conclusions at which he
arrives:

“1. There seems a definite relation between palate and cranium; certainly
as to length and breadth, probably as to outlines.

“2. In palatal deformity or interference with the mechanism of speech,
there seems to be in a large number of cases asymmetry of the brain-case.

“3. In strongly marked cases of malformation of the upper or lower jaws,
there is equally well-marked asymmetry of the skull.

“4. In a notable number of cases this flattening of the cranium is on the
left side.

“5. It is generally admitted that the language, speech, and sound centres
are chiefly on the left side of the brain.

“6. Evidence is obtainable that structural defects, mechanical injuries,
or pathological changes involving these parts produce defects of language
and speech.

“7. In so far as functional activity and capacity may be taken as
measures of organic perfection or otherwise, it may be assumed that
certain cases of cleft palate, or the subjects of some other deformities
in the maxillary region, who have also a deficiency in the articulate
sound function are also deficient in the articulate sound nerve-centre.

“8. And as it has been shown that congenital structural defect of the
brain is frequently associated with physical deformity of the skull, so
it may be useful to regard the conformation of the skull as part of the
evidence by which we may estimate the development of the brain.

“9. If it be possible to avail ourselves of the facts that are stated,
and the inferences that are indicated, we may be able to prognose with
a greater degree of certainty the future language and speech capacity
of sufferers from palatal and maxillary deformities of congenital
origin.”[65]

       *       *       *       *       *

We must now turn to the functional results of these deformities, and
trace out some of the effects which they produce on the economy.

[Illustration: FIG. 44.—Soft metal cover to teat of feeding bottle, which
can be moulded to the infant’s mouth, and act as an obturator during
suction. (_Mason._)]

We necessarily place in the front rank the serious difficulties met with
in the administration of _nutrition_. Where the lip alone is involved,
and that only to a slight degree, but little difficulty arises, as
the child is usually able to suck; but in the severer cases of cleft
lip, involving also the alveolus and palate, the child’s life may be
endangered from the inability to take or to swallow sufficient food. For
as the cleft alveolus and lip seriously impair the power of suction, so
the cleft palate allows the fluid which has found its way into the mouth
to regurgitate through the nose. In many such cases spoon-feeding is
the only chance for the child. To carry this out successfully the head
must be thrown well back, so that the fluid may pass directly into the
pharynx; in fact, the child is often obliged to drink like a bird, in
which, as is well known, the communication between the mouth and nose
through the non-union in the median line of the palate bones necessitates
a similar manœuvre. But even when this precaution is taken, there is no
doubt that many infants with fissured palate die of sheer starvation. Mr.
Mason suggested the use of an apparatus such as that figured below (Fig.
44). It consists of an ordinary india-rubber teat attached to a feeding
bottle. Over the teat is a very thin plate of soft metal, which can be
readily moulded to fit the infant’s mouth, and so act as a temporary
obturator. It may be used with advantage in some cases, but I have not
employed it largely, preferring to trust to careful spoon-feeding. A
similar contrivance in india-rubber which can be fitted to a Maw’s
feeding bottle has been successfully used. A covered spoon with apertures
left at either end is, in the hands of an intelligent nurse, an efficient
contrivance.

Coles has devised an artificial palate attached to a shield to go
over the mother’s breast (Fig. 45) in order to enable the infant to
take its natural nourishment. It is made of thin elastic rubber, is
not uncomfortable, can be kept perfectly clean, and from the shape in
which it is made can be used for either breast. In exceedingly delicate
children the employment of this device may be advisable.

[Illustration: FIG. 45.—Nipple shield suggested by O. Coles for use
in cases of cleft palate. A is the apparatus fitted to the breast,
and prolonged anteriorly so as to form a shield, which projects over
the nipple. When in the child’s mouth it acts as an obturator, partly
shutting off the nasal cavity. (_Coles._)]

In the severer cases it must not be forgotten that it is quite possible
that some other factor is engaged in the production of the rapid wasting
which in spite of every precaution may ensue, such as mesenteric
tuberculosis, or some congenital intestinal or vascular defect. Whether
such exist or not, the child quickly emaciates, the face becomes pinched
and old-looking; the skin has an earthy appearance and hangs in
wrinkles, lax and inelastic; and death, practically from starvation, soon
ends the chapter.

When our patient survives the dangers of infancy and arrives at boyhood
or girlhood, the regurgitation of food through the nostrils ceases,
except under occasional circumstances or in very severe cases; and
although the difficulties of infant nutrition are often manifested
in a much retarded growth, yet there is no reason why the physical
constitution of the patient should ultimately suffer. Again, the
knowledge of such visible and audible defects before operative treatment
has been undertaken has a decidedly depressing influence upon the mind.
The subjects of this deformity, from evident consciousness of their
repulsive aspect, shun the observance of others as they grow older; and
so strong is the sentiment which prevails as to maternal impressions that
they are studiously avoided by women in the earlier stages of pregnancy.
I have often noticed a distressed or hunted expression on the face of
those who had attained to adult life before surgical treatment had been
undertaken; and its disappearance after a successful operation has been
equally marked.

Defective _articulation_ is another serious accompaniment of these
deformities. Although this may be present to a slight degree as a result
of a simple cleft in the lip, yet it is only when the palate is imperfect
that the trouble is obviously manifest. The defect consists in the
inability to articulate distinctly any but the open vowel sounds, and
those few consonants which do not require the nasal cavity to be entirely
shut off from the buccal. For the production of the labials, dentals,
and gutturals, it is essential that there be a complete closure of the
posterior nares; and as the mechanism for effecting this is imperfect,
the production of the sounds must be similarly defective. In spite of
these difficulties, it is extraordinary how adults suffering in this way
can by practice make themselves understood. This inability to completely
shut off the nose from the mouth is undoubtedly the primary cause of the
nasal twang imparted to the voice. Even a small aperture is sufficient
to give rise to a marked defect in speech; whilst cases are recorded
where without any actual cleft the velum from deficient antero-posterior
length could not be approximated to the posterior pharyngeal wall, and a
similar condition of speech has resulted. Indeed, in many instances where
a scanty palate has been successfully sutured, the cacophonic sounds may
for a time persist, though to a less degree than before the operation, a
result either of inability to make this contact through an uncorrected
faulty habit or tension of the velum, or due to the presence of some
small opening. The peculiarity of the twang imparted to the voice varies
according to the amount of communication between the mouth and nose, the
size of the nasal cavities, and the shape of the nostril aperture. Where
the tonsils are enlarged, and adenoid vegetations exist in considerable
numbers on the pharyngeal wall, the size of the communication may be
reduced, and articulation thus rendered more distinct. It is a question,
therefore, whether these growths should be removed unless for some
pressing reason.

Singing is interfered with, though to a much less degree than is ordinary
speech, although the words sung will be indistinct. Whispering, moreover,
is impossible; but most of these conditions will not be very manifest
if the velum alone be fissured. Mason notes that it is very difficult,
and in some cases impossible, for the patients to blow out a candle; and
similarly they cannot perform on wind instruments.

The passage of air into the mouth and over the tongue tends to produce
dryness of the latter organ, and consequently excessive thirst. The
abnormal exposure of the parts to the unwarmed air produces a tendency
to nasal catarrh which is very decided; and, in fact, it is very common
to find a condition of chronic granular pharyngitis present, associated
with adenoid vegetations and chronic enlargement of the tonsils. Patches
or crusts of dried mucus may be observed clinging to the mucous membrane,
and these have occasionally been mistaken for sloughs. From these arises
a peculiar odour, which, however, cannot be quite accurately described as
fœtor. The falling of mucus into the mouth is another unpleasant result,
and the loss of the faculty of smell is in some cases most distinct.

The sense of taste is very defective in all severe cases, from the fact
that the tongue cannot be applied to the palatal surface in such a way
as to bring the food successively in contact with the organs of taste;
moreover, as is well known, the senses of smell and taste are closely
correlated, and where smell is absent, taste is deficient. This was very
well illustrated in one of my cases, where the operation for closure of
a complete cleft was not undertaken until the girl was twenty-five years
of age; it was entirely successful, and she told me subsequently that the
ability to appreciate the tastes of different foods in a way of which she
had no idea previously was not one of the least of the advantages derived
from the operation.




CHAPTER V.

OPERATIVE TREATMENT OF HARELIP.

    _Period of operation—Statistics—Precautions to be adopted._

    _Operation for single harelip: incisions; sutures; dressing;
    after-treatment—Various plans adopted._

    _Operation for double harelip: treatment of os
    incisivum—extirpation or reposition; treatment of soft parts._


In discussing the period in the infant’s life when a harelip should be
operated on, it may be laid down as a general rule that the sooner an
operation is performed for the repair of the abnormal condition _per
se_ the better; but other coexistent conditions have to be taken into
consideration, such as the amount of vitality, the degree of deformity,
and its association or not with cleft palate; and these may lead us to
postpone the operation.

A low state of vitality may be due either to a general inherited
weakness, or possibly to some associated deformity in another part of
the body interfering with nutrition; or, again, simply to difficulties
attending the administration of nourishment owing to the cleft lip and
palate; for, as has been already pointed out, suction, and therefore
breast-feeding, are impossible (p. 67). The problem that the surgeon
has to solve lies in deciding to which of these causes the asthenic
condition is mainly due, and whether the infant has sufficient strength
to withstand the shock of the operation, and is in a state favorable for
the occurrence of primary union. If due to some inherited weakness, or
associated deformity elsewhere, immediate operation would be rash in
the extreme, for the child is very likely to succumb. In any such case,
careful hand-feeding is alone practicable; if a steady improvement is
manifested, the operation may be undertaken later. But if, on the other
hand, the asthenia is evidently due to the inability to take nourishment,
the child gradually getting thinner and looking half starved (as I have
seen in many cases), then the first opportunity should be taken of
closing the lip, as such treatment holds out the only prospect of saving
the child’s life. The greater the deformity, the more difficult will the
question be to decide, for with the higher degrees of malformation the
operation necessarily increases in severity. If associated with cleft
palate this should be performed as early as possible, as the closure of
the lip enables nourishment to be taken when administered in the way
indicated above (p. 67).

It would be well here to call attention to the fact that the early
closure of the lip by the insensible and yet constant pressure brought
to bear on the separated maxillæ has a most beneficial effect in
narrowing the alveolar cleft. In my own experience I can testify to
the decided diminution which has occurred in the width of many clefts
when the lip had been closed by me some years previously, the patients
having subsequently returned for operative treatment on the palate.
Passavant[66] relates a case of a child whose harelip was closed at
the age of nine weeks, and a year later the palate was found to be
approximated without further operation, so that it merely presented
a fissure. Some surgeons have attempted to gain a similar result by
prolonged compression of the maxillæ. Trendelenburg,[67] on the other
hand, casts doubt on this explanation of the narrowing of the palatal
cleft, the existence of which he fully admits, stating he has seen the
same occur in children who have not been operated on, and suggesting
that it is due to the inward growth of the bones.

Three different periods have been suggested for the operation, viz.:

(_a_) The immediate operation—within two or three weeks of birth.

(_b_) The early operation—from three weeks to six months.

(_c_) The deferred operation—from six months to two years.

Statistics do not favour the immediate operation, for although some
surgeons have obtained good results, the mortality with others has been
considerable. Thus König,[68] on the one hand, records seventy cases
operated on in the first month with but one death; whilst Hermann[69]
gives 52·4 per cent. as the mortality of the operation during the first
three months of life, and Gotthelf[70] 50 per cent. for a similar
period. The latter cannot but be considered as an extraordinarily high
death-rate, and possibly antiseptic precautions were not carefully
observed. Trendelenburg[71] reports 44 cases treated in the course of
three years with seven deaths; the infants were between three and six
months old. Fifteen were simple cases, with one death; twenty-one were
complicated, with two deaths; and eight most complex forms, with four
deaths. Only one died within a fortnight of the operation; the remainder
from intercurrent maladies. Still, however, he reckons the death-rate
during the first year of life of children operated on as 41·6 per cent.,
explaining it by malnutrition and the want of intelligent artificial
feeding. Fritzsche reckons the mortality during the first two weeks after
operation as about 5 per cent., but even this is higher than I should
consider consistent with the results of British surgery.

My own personal experience has been much more satisfactory, and the above
figures are much too high to represent my results. Out of between 300 and
400 cases treated between the fourth and eighth weeks, _i. e._ by the
early operation, I have had no death as an immediate result, but several
have died subsequently from intercurrent maladies or defective nutrition.
I attribute this success largely to the fact that I never operate upon
out-patients, but always take the precaution of carefully preparing and
watching them for a few days prior to operating. In the practice of
the late Sir W. Fergusson the one or two fatal cases which I recollect
occurred in children who were taken home immediately after the operation.

It has been claimed for the deferred operation that convulsions are
liable to ensue when an infant under six months is operated on, and also
that the interdiction of nursing impairs nutrition; but this has not been
my experience.

From a consideration of the foregoing facts, it would appear that from
the fourth week to the third month is the most favorable period for
interference, and that at which the greatest proportion of success has
been obtained.

In conclusion, whilst fully admitting that it is impossible to lay down
rules which will meet every case, and that each must be dealt with on its
own merits, I would venture to suggest the following propositions which
may be helpful as a guide to practice:

1. That, _cæteris paribus_, it is important to close the cleft in the lip
as early as possible.

2. That, under ordinary circumstances, the immediate operation is
dangerous to life, and should only be undertaken in desperate cases as a
means of saving it,[72] _i. e._ in double cleft of the lip and palate,
where suction is impossible and swallowing difficult.

3. That experience shows that the sixth week may be taken as an average
at which operations can be safely performed; but that if the child be
very weakly, it is better to defer such treatment for a few days, until
careful spoon-feeding has improved our little patient’s condition.

4. That association with cleft palate in no way invalidates the previous
propositions.

In many cases of slight cleft without alveolar complication the child is
able to take the breast, and as it is desirable to maintain this after
the lip has healed, care must be taken that the lacteal secretion is
not checked. The child is often able to suck five to seven days after
operation; during that period the mother’s milk must be drawn off by a
breast-pump when necessary, and should be given to the child by spoon.
Any mammary inflammation is thus avoided, and the child’s diet is not
changed. In many cases of severe deformity, where the child is unable
to suck from the first, an early disappearance of the milk has of
necessity entailed spoon-feeding. When such an infant is taken from home
into hospital it is well to wait for a few days before operating until
acclimatised to the change of surroundings and of diet. The general state
of health should be as satisfactory as possible, and every effort must
be made to ensure this; it is often politic to defer operation on this
account for a short period. Any aphthous condition of the mouth should
be treated by swabbing with a weak boracic solution (1-40) or by the
application of mel boracis.

Anæsthesia is now-a-days invariably employed, chloroform being the agent
used. Care must be taken by the anæsthetist to prevent any drop coming in
contact with the wound, such an occurrence being liable to interfere with
primary union.

With regard to the position of the patient, some difference of opinion
appears to exist. The practice adopted years ago and described by the
late Sir W. Fergusson in his manual[73] consisted in the surgeon and
nurse sitting opposite one another, the latter holding the child with its
head on the surgeon’s knee. To quote his own words: “A cloth should be
wrapped round the chest so as to confine the arms; a pillow-case answers
the purpose well, as the legs can then be secured by slipping the patient
into it. Then the child should be held by an assistant with its head
resting face uppermost between the surgeon’s knees; if he puts on an
apron of waterproof cloth, it will answer the double purpose of keeping
his trousers free of blood, and preventing the child’s head falling too
low; a little pressure with the thighs will enable him to keep the head
more steady.”

The majority of surgeons at the present time employ the recumbent posture
on a table, a plan which I always follow, the surgeon standing behind the
child’s head, and the anæsthetist and assistant one on either side. Some
prefer to stand at the side of the infant, with the assistant behind its
head.


OPERATION FOR SINGLE HARELIP.

For convenience of description, the operation may be divided into three
stages:

1. Detachment of the lip from the maxillæ.

2. Preparation of the edges of the cleft.

3. Union by sutures, and application of dressing.


STAGE I.—_Detachment of the Lip from the Maxillæ._

The importance of thoroughly loosening the attachment of the lip to the
maxillæ and alveoli cannot be too strongly insisted on; and although
emphasized in monographs on the subject by several authors, yet in our
ordinary surgical text-books it is but scantily noticed or not alluded
to at all. Unless this proceeding is carried out efficiently, the
tension upon the stitches subsequently inserted will be so great as to
hazard successful union, and will prevent the surgeon from obtaining a
symmetrical adaptation of the parts. In severe cases it may be necessary
to carry the knife as far as the infra-orbital foramen, and I have often
had occasion to go close up to the orbital margin to gain as much freedom
as was needful. The maxillary attachment of the ala nasi must also be
completely divided, so that the flattened and distorted nostril may be
made to correspond in shape and form to that on the opposite side. This
dissection in single harelip is mainly needed to the outer side of the
cleft, but rarely to such an extent as described above unless the cleft
be very wide.

The knife must be kept close to the bone in order to minimise bleeding,
and not unnecessarily to lacerate muscular and other structures. Sponge
pressure will readily control any hæmorrhage. Afterwards the plastic
exudation that results is useful in steadying the mask of the face, and
the temporary division of facial muscles has a like effect.


STAGE II.—_Preparation of the Edges of the Cleft._

Many different methods have been suggested and practised for the
preparation of the margins of the cleft, some of which will be noticed
in detail hereafter. It is necessary to keep clearly in view the points
to be aimed at in the operation. The mere union of the two segments of
the divided lip is not sufficient; we also require to obtain symmetry of
the nostrils, to avoid an unsightly flattening of the tip of the nose,
to have a scar almost invisible, and no notch in the lip margin; the
muco-cutaneous line or red margin, moreover, should be so united as to be
continuous.

Many surgeons have endeavoured to utilise almost, if not every particle
of tissue bounding the cleft, notably Malgaigne, Nélaton, Henri, and
Giraldés; but the principal objections to this are that it leaves the
nostril wide and depressed, and the expression anything but agreeable,
whilst in some of the plans suggested the muco-cutaneous line will be
irregular. From my own experience of operations I am convinced that
better results may be obtained by a free removal of tissue, principally
from the outer or buccal half of the cleft; and in so doing the knife
should always encroach upon the affected nostril, and thus the necessary
diminution in the size of its aperture can be obtained.

Bearing in mind the tendency of scar tissue to contract in all
directions, it is obvious that the surgeon must so plan his incisions
that the united lip shall be at first slightly longer vertically than is
ultimately desired. The incisions, instead of being made parallel to the
edges of the cleft, should be curved, with their concavities facing each
other, so that when in apposition a vertical elongation may be obtained.
To avoid the formation of a 𝖵-shaped notch, a result so liable to occur,
a variety of methods of forming a _prolabium_ have been suggested and
practised. Most of these aim at the formation of a protrusion which,
exaggerated at first, will ultimately be reduced to normal dimensions by
subsequent cicatrisation. Some surgeons (_e. g._ Mirault and Giraldés)
are content with using the mucous membrane of one side only, and planting
it on a prepared surface on the other margin of the cleft; whilst
Malgaigne, Henri, and Stokes make use of labial tissue from both sides.
My usual plan of procedure is a modification of that described by Dr.
Stokes, though I have had recourse to other methods.

Great care must be taken to make the incisions clean and at right angles
to the skin. By some, however, the edges are bevelled, and when for any
reason such is thought desirable it is important to remember that each
side will need bevelling to a proportionate extent. The use of scissors
for this purpose is sometimes preferred to that of the knife, but the
difficulty of cutting cleanly appears to me much greater with scissors,
however sharp, than with a scalpel.

Various kinds of lip compressors have been suggested for controlling the
hæmorrhage from the coronary arteries during this stage of the operation;
but I agree with the majority of surgeons in considering that these are
cumbersome, and quite unnecessary when one has intelligent assistants.
The constant presence of such an instrument distorts the parts, and
prevents the operator from seeing clearly how to plan his incisions.
Nothing can be so well adapted for this purpose as the thumb and index
finger.

The usual method that I am accustomed to adopt for cases of simple
unilateral harelip is as follows:—Standing behind the patient’s head,
and my assistant holding the right side of the lip between the finger
and thumb of his right hand, so that the index finger is in the mouth,
and so holding the lip forward and inward at a sufficient distance
from the margin to enable me to remove the requisite amount of tissue
without difficulty, I enter the knife with its edge downwards either
at the apex of the cleft, or in a complete case at the margin of the
nostril as high as desirable, and cut in a curved direction downwards
until the muco-cutaneous junction is reached. The edge of the knife is
then turned so as to cut through the mucous membrane of the lip in a
direction practically at an angle of 60° to the former incision. Then
grasping the left side with my own left thumb and forefinger, and thus
making it tense, I make an exactly corresponding incision, dealing with
the muco-cutaneous margin and mucous membrane in a similar manner (Fig.
46 A). Having approximated the edges and fitted them together, we are now
ready to undertake—

[Illustration: FIG. 46 A.—Author’s method of preparing edges of cleft,
showing semilunar incision as far as red margin of lip, and oblique
upward cut on either side to form the prolabium.

FIG. 46 B.—Shows flaps in position, and the nostrils symmetrical. The
wide stitch lines represent the position of the wire sutures, the narrow
those of the catgut.]


STAGE III.—_Union by Sutures and Application of Dressing._

Many surgeons still retain the plan first introduced and figured by
Ambrose Paré[74] of uniting the edges by means of harelip pins and
figure-of-8 sutures; but this has been largely superseded by the use of
silver wire and intermediate fine sutures.

Good results undoubtedly followed the old plan of treatment, and it had
the advantage in pre-anæsthetic days of being more rapidly accomplished.
But success could not be depended on for the following reasons: it was
more difficult to adjust the edges with exactness, and the muscular
movements of the lip were liable to cause them to slip, and being hidden
by the coils of superjacent suture the displacement was undetected until
the removal of the pins. Moreover the track of the pins, especially if
they were retained beyond the fourth day, was liable to become the seat
of suppuration, and unsightly cicatrices resulted. In some instances
the pins cut their way out of the lip, leading to still more evident
cicatricial deformity, and the liability to septic infection of the wound
was of course much greater. At the same time I have no desire to detract
from the one great and acknowledged advantage of pin-transfixion and
figure-of-8 suture, viz. the steadying and accurate approximation of the
deeper parts, when efficiently inserted; but I maintain that the same
advantages can be secured by the use of silver wire as detailed below.

When harelip pins are used, the method of introduction is as follows:—The
first pin should be inserted close to the muco-cutaneous margin, and
about one centimetre from the edge of the right side of the lip, and
its point should emerge on the deep aspect of the raw surface close to
the mucous membrane. It should then be passed on through the opposite
side of the lip, entering at an exactly corresponding point on the raw
surface, and passing out through the skin of the left side at the same
distance from the edge as on the other. One or two more pins should be
similarly passed at equal distances through the other portions of the
cleft. Moderately thick unwaxed silk is now used as a figure-of-8 suture,
whilst during this the assistant presses the cheeks, and holds the lip
_in situ_. The parts should not be dragged together by this means, but
merely retained in the position to which they have been easily brought
by the pressure of the assistant’s fingers, as a result of the previous
undercutting. A separate silken thread is advisable for each pin. The
pins are now cut short by wire-nippers, and collodion painted over all.

The plan I now adopt, in common with many others, of suturing the
prepared lip is as follows:—Purified silver wire of No. 27 gauge is
carefully threaded on special wire needles. I introduce two or three
sutures by entering the needle at rather more than half a centimetre from
the margin, and bringing out the point on the raw surface close to the
mucous membrane as with the pins, taking care to pass the needle in on
the opposite side at an exactly corresponding point. The three situations
I select for these sutures are, one at the root of the nose or upper part
of the cleft; one a little above the muco-cutaneous junction; and the
third, if necessary, between the other two. In very young infants and
simple cases, only two wires are needed.

Having passed the wires and tested the accuracy of their position,
the ends are left long and unfastened lying on the cheeks, whilst the
fine catgut sutures are being adjusted. By means of small semicircular
needles, about two centimetres in diameter, held in a needle-holder,
these sutures are inserted, as near to the margin of the cleft as is
possible, consistent with their holding. The first two should be placed
one at the muco-cutaneous junction, and the other at the nostril aperture
as high as is necessary in order to bring about the approximation of the
ala nasi to the median line, and thus secure the diminution in the size
of the opening, and a symmetrical disposition of the features.[75]

As many other fine sutures as are necessary are now inserted between
these two. In regard to the mucous membrane of the lip and the formation
of the prolabium, care must be taken that the exact edges are stitched
together, as they are very liable to curl in. It will be found of great
assistance if the catgut of the first suture in the mucous membrane be
not cut short, but used as a holder to lift the lip during the passage
of the next stitch, which will fulfil the same office for the succeeding
one, and so on, until, in this way, the mucous membrane can be thoroughly
everted, and fine sutures carried through the edges on the buccal aspect.
The effect of this is most satisfactory in maintaining exact coaptation
of this part of the lip, which is so liable to be displaced when the
child is fed or cries, permitting the entrance of food or saliva which
will interfere with the progress of union. The wire stitches (sutures of
relaxation) are now fastened, and in doing so there is no necessity to
tighten them unduly; experience alone can teach the requisite amount of
tension. This completed, all traces of blood are removed from the face,
and the sutured lip carefully cleansed with a purified sponge dipped in
boracic acid lotion.

A collodion dressing is then applied in the following manner: a piece of
antiseptic gauze folded double is cut butterfly fashion, so that one wing
is fixed upon each cheek, and the uniting portion, just the width of the
lip, passes over the wound. Collodion is carried close up to, but not
over, the wound itself, which is merely covered by the bridge of gauze.
During the adjustment of the dressing, the assistant should hold the
cheeks forward, and this position must be maintained until the collodion
is firm. The contractile nature of this dressing is especially useful in
limiting to some extent the movements of the cheek.

In former days the use of Hainsby’s truss or cheek compressor was much in
vogue, with the object of relaxing, as far as possible, all tension on
the flaps; but the apparatus has now been discarded by most surgeons. The
pressure of the spring was occasionally so severe as to cause sloughing
of the cheek (as I have seen in one or two cases many years ago); or
else there was a great liability for the pads to slip out of position
during any sudden movement of the child’s head, leading to injurious
pressure on or near the wound itself. In fact, if the truss was acting
efficiently, pain and irritation to the child resulted; if it was
comfortable, it was generally useless.

One of the principal points to be attended to in the _after-treatment_
is to instruct the nurse to depress the lower lip with the index finger
for some hours after the child has recovered from the anæsthetic, and to
repeat it occasionally until it becomes accustomed to the diminished oral
aperture; otherwise the efforts to draw air through the mouth (now closed
for the first time) will tend very considerably to disturb the wounded
surfaces.[76]

Spoon food must be so administered as to allow it to touch the upper lip
as little as possible. The arms should be fixed to the side to prevent
them touching the face. In young infants constant attention day and night
is necessary, for they are very liable to roll the head from side to
side, and so bring the sutured lip in contact with the bedclothes, which
causes pain and makes the child cry, a most undesirable occurrence. The
state of the bowels should be attended to, and if constipation exist,
a small dose of grey powder with magnesia may be advisable. The silver
wire sutures should usually be taken out on the fourth day; the catgut
stitches may remain a week, or some of them until absorbed, the collodion
dressing being re-applied when necessary, and maintained for a few days
after the catgut has disappeared or been removed. Occasionally saliva
and milk soak into and under the gauze, producing a moist condition of
the skin around the freshly united wound, which may lead to eczema. The
gauze should then be left off, and the parts gently washed with warm
boracic lotion and dusted over with a mixture of equal parts of powdered
oxide of zinc and starch. In mild cases without alveolar complication
the child may be put to the breast on the fifth or sixth day, if the
condition of the wound is satisfactory. But in the severe forms, or where
the union is weak and threatens to give way, most careful spoon-feeding
and general watchfulness must be continued. In spite, however, of every
precaution, the depression of the nostril will sometimes persist or
reappear as cicatricial contraction takes place, and a slight notch in
the lip cannot be always prevented.

It will be convenient to append here a description of some of the better
known methods of operating on unilateral harelip, with a few words of
criticism on each.

       *       *       *       *       *

1. _Graefe’s method_ is applicable only to incomplete clefts in the soft
tissues. He prepares the edges by an arch-like incision (Figs. 47 A and
B), and brings them together with the muco-cutaneous margin even. It will
be seen that a notch must necessarily result (in spite of the successful
appearance in the picture which I have borrowed) from cutting the red
margin of the lip in this manner.

[Illustration: FIG. 47.—Graefe’s operation. The completed lip is an
impossible diagram of the result of such a section.]

2. _Nélaton’s method_ (Figs. 48 A and B).—In this no tissue is removed,
but the margin is freed by a semicircular incision skirting the cleft
and extending through the whole thickness of the lip. The centre of the
fissure is then drawn down, and the opening thus created is brought
together laterally so as to cause the lower portion to protrude as a
prolabium. It is only suitable for very mild cases of harelip where the
nostril is not involved, and has been adopted in the secondary treatment
of the 𝖵-shaped notches, the results of previous operations. It will
be noted, however, that the prolabium in this case consists mainly
of cutaneous tissue, and that there must necessarily be an unsightly
break in the red margin of the lip, which makes it a most undesirable
proceeding.

[Illustration: FIG. 48.—Nélaton’s operation. No tissue removed, but the
loosened margin pulled down and sutured.]

3. _Malgaigne’s operation_ (Figs. 49 A and B) was suggested for
unilateral harelip where the fissure does not extend into the nostril.
No tissue is removed, but flaps are turned down from the apex of the
cleft on either side, the incision stopping at the red margin of the
lip. Knife or scissors may be used. The flaps are drawn down and united
to form a prolabium, whilst the raw surfaces, necessarily left above,
are united from side to side. The same objection applies to this as to
Nélaton’s operation, viz. the break in the red margin of the lip caused
by the interposition of integument.

[Illustration: FIG. 49.—Malgaigne’s operation. No tissue removed; cleft
margins turned down to form a prolabium.]

4. _Giraldés’_[77] _or the mortise operation_ (Figs. 50 A and B) is a
somewhat complicated proceeding. Taking a left-sided unilateral cleft for
illustration, a flap (_a_) is cut on the right side from below upwards,
starting from the muco-cutaneous junction, and remaining attached by
its base to the root of the nose. The portion of red lip margin below
this is removed by an oblique incision (_c_), and so prepared for
receiving a flap from the other side. On the left side of the cleft,
a flap (_b_) is made by cutting from the ala nasi downwards to the
muco-cutaneous junction, leaving it attached below; and in addition
a transverse incision outwards is made from the same starting-point,
skirting the nostril if necessary. The right-hand flap (_a_) is turned up
and implanted along the opening made by the transverse incision, whilst
the left-hand flap (_b_) is turned down and implanted on the oblique raw
surface (_c_). It will then be easy to approximate the surfaces _d_ and
_e_ together as indicated in the figured diagrams. I have not practised
this identical operation as described above, because of the objection
there is to the left-hand flap, which contains skin at its upper part,
being introduced into the red margin of the lip.

[Illustration: FIG. 50.—Giraldés’ or the mortise operation.]

5. _Mirault’s operation_ (Figs. 51 A and B) consists in entirely removing
the inner margin of the cleft, whilst on the outer side a flap is turned
down by cutting from above downwards, commencing at or near the apex and
extending to the junction of the middle and lower thirds where it remains
attached. Care must be taken to make this flap sufficiently thick. It is
then carried horizontally across the cleft and applied to the opposite
margin, and the raw surfaces sutured together. The same objection may
be raised to this as to some of the above-mentioned operations, viz.
the implantation of integumental tissue in the continuity of the mucous
membrane of the lip, resulting probably in an irregularity of the red
margin.

[Illustration: FIG. 51.—Mirault’s operation. Outer side of cleft margin
implanted on prepared surface of inner side.]

6. _König’s operation_ is more satisfactory, and not unlike the one I
usually employ (Fig. 46). It consists in paring both margins of the
cleft, and in then forming two small prolabial flaps by horizontal
incisions parallel to the lip margin.

7. _Stokes’s operation._—In this a prolabium is formed by tissue from
both sides of the cleft by means of incisions skirting the red margin of
the lip, as seen in the drawing (Fig. 52, _ab_, _a′b′_). The upper part
of the cleft is not completely pared on either side, but the knife is
only carried three quarters of the way through the thickness of the lip,
the mucous membrane remaining intact. These partially dissected flaps are
turned back, and the edges of the skin brought into apposition, whilst
the prolabial flaps are drawn downward and outward. As regards the latter
part of this proceeding, it will be seen that my own plan is much the
same, but the necessity for leaving the tissue at the back of the lip
does not appear to possess any advantage commensurate with the greater
difficulty that its presence entails in the accurate adaptation of the
flaps.

[Illustration: FIG. 52.—Stokes’s operation. Prolabium formed by flaps
_ab_, _a′b′_ from each side; margins of cleft partially detached, and
flaps K B _ab_, K B _a′b′_ turned backwards to increase breadth of raw
surface. (_Mason._)]

8. _Collis’s operation_[78] (Figs. 53 A and B).—This proceeding is
somewhat similar to Stokes’s as regards the utilisation of every portion
of the soft tissues. On the inner side the knife is carried along the
margin of the cleft (_a b_), but stops short at the mucous membrane,
allowing this portion to be turned, as on a hinge, backwards to increase
the thickness of the raw surface. On the outer side a prolabial flap (_e
f_) is made from above downwards, starting at the centre of the margin,
whilst the rest is turned upwards to form a flap attached above (_c d_).
This latter is then drawn across and adapted to the upper part of the
inner margin with its apex upwards, whilst the lower flap is drawn across
and implanted on the lower portion with its apex downwards. In actual
practice this is complicated and tedious, but the principal objection to
it as well as to Stokes’s operation lies in the fact that there is no
provision for restoring the shape of a distorted nostril.

[Illustration: FIG. 53.—Collis’s operation. No tissue removed. Inner
margin is pared by incision _a b_, but left attached by mucous membrane,
and hinged backwards. Outer margin is transfixed, and flaps _c d_ and _e
f_ are cut; _c d_ is turned up and attached to _a g_; _e f_ is turned
down and attached to _b h_. (_Mason._)]

In the severer forms of harelip, where either the cleft is broad or the
nostril much flattened, other modifications may be necessary; such, for
instance, as that practised by Dieffenbach, the essential principle of
which consists in making additional incisions horizontally below, and
even skirting around the ala nasi, with the object of so loosening the
tissues as to bring them more readily into apposition. I have never
practised this, and cannot help thinking that the difficulty often
experienced in bringing a flattened nostril into position would be rather
increased than otherwise. Free undercutting of the cheek tissue will
probably be found much more efficacious.

In alveolar harelip with projection of either segment of the alveolus
it may be necessary to excise the projecting portion, or to reduce its
bulk in order to prevent undue tension on the flaps. In many it is
sufficient merely to excise the milk tooth, whilst in others a part of
the bony margin may need removal with cutting pliers. Any such step, when
obviously necessary, should be carried out as a preliminary operation.


OPERATIVE TREATMENT OF DOUBLE HARELIP.

This subject naturally resolves itself into the discussion of two points,
viz. the method of treatment of the os incisivum, and that of the soft
parts.

The treatment of the os incisivum has given rise to considerable
discussion, and the practice of various surgeons differs greatly. Whilst
some, especially on the Continent, have advocated its retention, others,
particularly of the English school, have just as strongly urged its
extirpation. One thing is plain; if the bone is to be retained steps must
be taken to restore it to a normal position. It will be well to describe
_seriatim_ the different plans of treatment which have been suggested,
and subsequently to discuss their relative value.

The oldest and simplest method consists in the complete removal of the
bone, or, as it is sometimes called, the operation of Franco.[79]

This should be always undertaken as a preliminary step a week or two
prior to dealing with the soft parts, and is effected in the following
manner:—The central portion of the upper lip, together with all the
available tissue which can be turned up, is first dissected away from the
bone and left attached to the columna nasi. The mucous membrane behind
the projection is then incised transversely to allow of the introduction
of a pair of cutting pliers, by which the separation of the bone from
the vomer is effected. Smart bleeding from the anterior palatine vessels
frequently occurs, and may require a touch of the cautery to stay it. No
after-treatment is necessary, as the stump rapidly cicatrises. The child
should be well fed up in view of the subsequent operation upon the soft
parts.

Where the os incisivum is retained, the following methods for its
treatment have been adopted:

1. Gradual and continuous backward pressure by means of a bandage
(Desault). In this plan the bandage requires constant attention to keep
it sufficiently tight; and it is very doubtful whether much effect can
be thus produced, especially when only applied, as in Desault’s cases,
for from ten to eighteen days. The use of elastic tension by means
of india-rubber has been also recommended (Thiersch). The effect of
such treatment will be to bend the vomer in proportion to the amount
of repression; but much pain must always be produced by this process,
and the vitality of the central part of the upper lip may be seriously
impaired.

It would appear from Desault’s writings that he only advised this
proceeding in cases where the projection of the bone was slight, and
where there was a certain amount of mobility owing to the median septum
being soft and cartilaginous, conditions which do not often obtain; and
certainly statistics do not show any large number of cases treated.

Where, however, the projection is but slight, and the vomer not too
strong and hypertrophied, this plan deserves a trial prior to undertaking
more serious steps.

2. Forcible repression of the incisive bone by seizing the projecting
tubercle at its extremity and violently forcing it back, fracturing the
bony processes which support it. This proceeding, which was introduced
by Gensoul of Lyons, rests on the theoretical hope of simply fracturing
its pedicle at its narrowest part without giving rise to much hæmorrhage,
or to laceration of the mucous membrane. But anatomical facts are
opposed to such a probability. The vomer, we know, is usually thick and
hypertrophied in these cases, and the line of fracture will probably be
far back, and may very possibly extend to the cribriform plate of the
ethmoid and base of the skull. The mucous membrane, moreover, is liable
to be severely lacerated and the hæmorrhage considerable; Sédillot[80]
sums up the proceeding as “peu sûre, difficile toujours, et impossible
souvent.” But few cases of success are recorded, and from its uncertainty
one may dismiss it as unscientific and unjustifiable.

3. Repression after excision of a wedge-shaped piece of the vomerine
plate immediately behind the os incisivum (Blandin’s method).[81] This
only applies to cases of complete double cleft where the vomer is
unattached to either palatal segment. Using strong scissors, M. Blandin
cut out a 𝖵-shaped portion of the vomer, the anterior incision being
vertical and the posterior oblique. The median tubercle could then be
easily replaced. The great objection to this method, however, is the
severe hæmorrhage which is liable to ensue from the divided anterior
palatine arteries, and, in fact, M. Richet reported three cases in
the ‘Société de Chirurgerie,’ in 1856, in which he had performed this
operation, and all with fatal results.

A much better plan is that which was suggested, in order to avoid such
mishaps, by Bardeleben.[82] He incises the mucous membrane along the
lower border of the nasal septum behind the os incisivum, and then strips
up the mucous membrane and periosteum by means of a narrow-bladed
raspatory. The septum may be either divided with cutting pliers and
the projection thus reduced, or being grasped by a pair of sequestrum
forceps, the blades of which are protected by gutta percha, may be
diminished in length by being forcibly twisted upon itself. The effect
of either of these proceedings will be to cause the two portions of the
vomer to overlap, a matter of little consequence, whilst the operation
being subperiosteal, but slight hæmorrhage occurs. The results of this
method of treatment seem to have been fairly satisfactory.

The late Mr. Butcher[83] designed certain ingenious instruments for
“cutting through the projecting pieces in complicated harelip without
dividing the soft parts,” or interfering with the vascular supply from
behind previous to bending them back.

By whatever method the median tubercle has been replaced, it is always
advisable to operate at the same time on the soft parts, as the united
lip is the best splint for steadying the bone in its new position and
giving it as good a chance as possible for becoming fixed. To assist this
fixation various plans have been adopted, but with very partial success,
_e. g._ the lateral aspects of the cleft and the os incisivum have been
freely pared in order to obtain firm adhesions of the raw surfaces, and
even silver wires have been passed, a proceeding somewhat detrimental to
the developing teeth.

Langenbeck,[84] after paring the edges of the prominent tubercle and of
the maxilla, transfixed the parts with a harelip pin after replacement
into position, and I have myself tried the same plan, but with
indifferent success.

In discussing the relative merits of these two forms of treatment,
extirpation or reposition, it must be remembered that the latter is
practically impossible in adults or in patients rather older than the
usual infants operated on, for the os incisivum will in such be larger
and more bulky than usual, and the palatine cleft having become narrower,
the space into which the bone has to be repressed is much smaller than
usual. The advantages claimed for reposition are the following:

1. The profile view of the face is much improved by retaining the normal
shape of the alveolar border, and the appearance, especially when the
mouth is open, as in laughing or yawning, is more pleasant.

2. The normal contour and size of the upper jaw is maintained, preventing
the patient from becoming so obviously “underhung” as is commonly the
case after extirpation.

3. The patient retains his own teeth, and is able to use them better than
any artificial appliances.

But such advantages are more theoretical than practical, as the following
facts will show.

The os incisivum in its new position is admittedly never very firm, and
usually has considerable mobility, and hence its use in bearing the
incisors is considerably discounted. Moreover the position of these
teeth is such that they are both useless and unornamental; for from the
rotary movement by means of which reposition is effected, the teeth will
generally erupt obliquely backwards; they are in addition often small and
decayed. Although it may be desirable to maintain the normal contour of
the jaw, we must assert that the presence of the incisive bone between
the anterior portions of the maxillæ is by no means an unmixed good, as
its wedge-like action interferes materially with the subsequent narrowing
of the palatine cleft, and so renders the later operation for the cure of
this defect more serious and difficult.

Again, it has been already pointed out that it is desirable to complete
the operation on the lip simultaneously with the reposition of the
median projection; the effect of this more serious step is manifestly to
increase the shock to the little patient, who is probably not in the most
vigorous condition of health from its inability to take nutriment in the
usual way, and at any rate renders the occurrence of primary union less
likely. This fact may perhaps explain the much higher death-rate after
operation amongst German surgeons than in this country. The prominent
condition of the under lip (Fig. 75, p. 147) can be remedied later on
by excising a 𝖵-shaped portion from its centre, resulting in marked
improvement to the facial expression, especially in patients operated on
after infancy.

To my own mind the disadvantages of the retention of the incisive bone so
clearly outweigh the _prima-facie_ advantages, that in my practice I have
followed the usual course adopted by the majority of British surgeons
in removing the bone at the earliest opportunity. By this removal the
operation on the lip can be more successfully accomplished, and as
regards the profile effect the later introduction of a dental plate with
artificial incisors will greatly improve the appearance, and enable the
patient to bite in a satisfactory manner, far more so, in fact, than with
the mobile os incisivum.

After removal of the bone and union of the lip, the approximation of
the maxillæ to one another has been repeatedly observed and accurately
noted. Whether this is due to the insensible pressure of the united
lip or to increased osseous development is a matter of but slight
importance; probably both agents contribute to this desirable effect.
If, however, the maxillæ are considerably drawn together, the “bite” or
dental adjustment between the upper and lower jaws becomes uneven, _i.
e._ the upper teeth fall within the lower so that during mastication,
side-to-side movements of the mandible, as seen in horses and cows,
become needful.

After the child has recovered from this preliminary operation of
extirpation of the incisive bone, and the raw surface left by its
removal has cicatrised, the soft parts of the lip are then dealt with.
This cannot be well undertaken before the tenth to the fourteenth day.
The operation, so far as the lateral segments are concerned, should be
carried out according to the principles enunciated for the single harelip
operation. A free detachment of the lip from the maxillæ by undercutting
should be the first step, and this must be accomplished thoroughly
in these bilateral cases. The edges will then require preparation by
curved incisions made from above downwards as far as the muco-cutaneous
junction, and then prolabial flaps are formed by cutting upwards and
inwards at an angle of 60° to the preceding (Fig. 54 A).

[Illustration: FIG. 54.—Author’s incisions for double harelip. The
central tubercle is pared in a 𝖵-shaped manner, and the lateral segments
by curved incisions from above down to the muco-cutaneous junction,
and then obliquely upwards and inwards. Only the apex of the central
portion is included in the completed lip. The long cross lines represent
the position of the wire stitches, and the short ones of the catgut
sutures.[85]]

The treatment of the central part of the upper lip demands special
notice. In the first place it is quite evident that to attempt to
draw it down to any extent between the flaps would have the effect of
depressing the point of the nose and producing an unsightly lateral
dilatation of the nostrils, for it must be remembered that this stunted
portion of tissue represents in most cases not only the central part of
the lip, but also the columna nasi. Very commonly there is but little
more tissue than will suffice to form a columna. Though thus deficient
in length it is often broader than is necessary, and may subsequently
require further operative treatment to reduce it to a shapely size (p.
148); otherwise it encroaches too much upon the nostrils, and is very
unsightly. Consequently it is only the extremity of this philtrum which
needs preparation, and this is effected by cutting it into a 𝖵-shape,
the raw margins thus exposed being carefully implanted between the edges
of the lateral flaps at the upper part (Fig. 54 A). Wire stitches are
now passed; the upper one should traverse the apex of the 𝖵, and other
fine catgut sutures should be used for accurately adjusting this central
portion. The outer segments can then be brought together in the median
line in the manner previously described in the operation for unilateral
harelip (Fig. 54 B).

Several other operations have been suggested, and notable amongst
them are those of Sédillot and Mr. Thomas Smith. The former devised a
cheiloplastic method of remedying this double deformity, the incisions
for which are shown in the accompanying engraving (Fig. 55). Flaps _aa_
consisting of the outer margins of the clefts are turned down to form
the red border of the completed lip, and united in the middle line,
whilst oblique incisions are made upwards and outwards to free the outer
segments. The central tubercle is pared, leaving raw surfaces (_b′b′_),
to which are applied by suture the surfaces (_bb_) made by the oblique
incisions. I cannot but think that the objections stated above to a
similar plan suggested for single harelip are equally valid as regards
this method (p. 91), viz. that the nasal distortion is less easily
remedied by this plan than by the free under-cutting of the segments
which I invariably practise.

[Illustration: FIG. 55.—Sédillot’s operation for double harelip. _a a._
Prolabial flaps to form red margin of lip by union in middle line. _b b._
Incisions below alæ nasi to permit approximation of the above. _b′ b′._
Incisions in sides of central tubercle. (_Mason._)]

The latter operation (T. Smith’s, Fig. 56) is only adapted to those rare
cases where the soft tissues of the central tubercle are abundant. He
turns down marginal flaps from this central part and implants them on
prepared surfaces of the outer segments. The apex of the philtrum thus
forms the central part of the united lip; hence there must not only
be a tendency to depression of the point of the nose, but also great
probability of a decided notch subsequently manifesting itself in the
median line, when cicatrisation is complete.

[Illustration: FIG. 56.—T. Smith’s operation for double harelip. The
outer segments are pared and the parings removed. Prolabial flaps are
turned down from the sides of the central tubercle. Evidently it can only
be of use where the soft tissues are abundant. (_Mason._)]




CHAPTER VI.

OPERATIVE TREATMENT OF CLEFT PALATE.

    _Period of operation.—Preparation of
    patient.—Anæsthesia.—Duties of the
    assistant.—Instruments.—Description of uranoplasty; of
    staphyloraphy.—After-treatment.—Complications.—Modifications of
    operation._


The period of life at which an operation can be safely undertaken for
Cleft Palate is a matter which demands careful consideration. Before the
introduction of anæsthesia the assent of the patient was required, and
therefore the operation was seldom performed before the age of puberty.
With the aid of chloroform this is obviated, and we can now operate
at an earlier period; undoubtedly as regards the subsequent power of
articulation the earlier the operation is performed the better. On
the other hand, the palatal tissue in infant life is so delicate, and
the cavity of the mouth so small that a plastic operation is attended
with more than usual difficulty. Further it is almost impossible to
keep an infant sufficiently quiet to allow of primary union, as it is
constantly interfering with the stitches by pushing the tongue against
the wound, and sucking the edges apart. Statistics of results, moreover,
tend to prove that such operations conducted on young infants are not
only directly dangerous to life, but also indirectly, by depressing the
general vitality and increasing the liability to subsequent disease. Thus
Ehrmann[86] records ten cases operated on under two years of age with
two deaths, two failures, and six cures, which latter he considers due
to the fact that the children were fed after the operation by œsophageal
tubes passed through a protective plate of hardened rubber so as to
prevent interference with the sutures. Of these six cases cured, only
one was living after four years had elapsed, and in this the soft palate
only had been closed. He considers that the loss of blood, and the shock
of the prolonged operation or operations interfered in a serious manner
with the vitality of the patients. These are, perhaps, somewhat scanty
facts to argue from, but they tend to show that there is a greater risk
associated with operations performed at an early period of life, although
we have the authority of many well known surgeons for attempting them.
Thus Billroth has operated at the age of four weeks, Roye of Lausanne at
eight days; but my own experience is certainly in favour of deferring
operation until the child is at least three years old, or as soon after
that period as possible if it is at all of a tractable disposition; the
moral control at this age is usually sufficient for our purpose.

As to whether the whole cleft should be dealt with at one operation or
not, the practice of surgeons differs considerably; and indeed each
case needs to be decided upon its own merits. Where the cleft merely
involves the soft palate, or possibly extends but for a short distance
into the hard, one operation will usually suffice; but in extreme cases
of complete cleft of the hard and soft palate with wide separation of
the edges, it may be advisable to deal at different times with the hard
and soft, some preferring to close the hard at the first operation,
and others the soft. This must depend upon the surgeon’s confidence in
himself and in his patient. Personally I always prefer, if practicable,
to obtain union in the hard palate at the first operation; then if after
taking the necessary steps for loosening the muco-periosteal flaps the
parts appear to come easily together, the edges of the whole cleft can
be pared, and the whole process completed at one sitting. I cannot too
strongly insist on the paramount importance of obtaining firm union in
the anterior part of the palate, for if the smallest opening be left in
that situation, distinctness of speech in after-life will be seriously
impaired.


PREPARATION OF PATIENT.

The state of the health and the local conditions of the mouth, nose, and
pharynx must be carefully examined before the operation is decided on.

The little patient’s general condition must be as satisfactory as
possible, and a course of tonic preparatory treatment (including possibly
a change to the seaside) is often advisable. Sources of infection from
measles, &c., should be carefully avoided, and for a few days prior to
the operation they should be kept under observation and at rest, to
prevent any likelihood of catarrhal developments.

The local conditions, too, must be satisfactory. There should be no
excessive secretion from the naso-pharyngeal mucous membrane, as such
is usually associated with an œdematous infiltration of that structure,
most unfavourable to the attainment of primary union; and, moreover, this
excess of mucus tends to insinuate itself between the edges of the flaps.
If present, it should be treated by rest in a warm mean temperature,
bland diet, and the application locally of gargles of boracic acid and
chlorate of potash, combined with the careful use of astringents such as
tannic acid and alum; the tongue also should be clean. The state of the
tonsils should be looked to, and when greatly enlarged they ought to be
previously removed, for they may materially interfere with the union of
the palate, either from their size, or from the possible supervention
of inflammation; when only moderately enlarged there is, I believe, no
necessity for their removal; on the contrary they subsequently assist in
closing the aperture between the nose and mouth during speech. Similarly
post-nasal adenoid growths should not be interfered with, unless
absolutely necessary (p. 70).

For the _immediate_ preparation of the patient it is advisable that
the bowels should be moved the day before operation, that no food be
administered for at least six hours previously, and fluids only for some
hours prior to this.

The patient should be placed on a suitable narrow table in such a
position that the light falls well into the mouth. Where practicable,
a graduated head piece capable of being raised and lowered, in order
at one time to throw the light on the soft, and at another on the hard
palate, is desirable; but in private houses this is usually attained
by a due adjustment of pillows. To prevent any sudden movement on the
part of the patient the hands should be fixed to the side, and my usual
method of accomplishing this is to pass a leather strap around the thighs
immediately below the trochanters, and to this the wrists are attached
by means of leather bracelets locking on to the circular strap by spring
hooks. This plan of fixing the arms enables the patient to be turned from
side to side to allow blood to pass out of the mouth when respiration
becomes embarrassed by an accumulation in the pharynx. If the patient is
strapped down to the table, this cannot be accomplished, and the plan
just indicated will be found of great practical value. For it must not be
forgotten that the anæsthesia is not always so deep as to prevent sudden
reflex movements of the hands, which might jerk the operator’s knife and
cause serious mischief.

To obviate the dangers arising from the flow of blood into the pharynx
and larynx, it has been recommended by Prof. E. Rose of Berlin to
operate with the head hanging over the end of the table, thereby
causing the blood to gravitate into the nose. I have only adopted this
suggestion in one or two instances, but in those in which it was tried
considerable congestion of the vessels of the head was produced, and the
administration of the anæsthetic interfered with. A skilled assistant
should to my mind render such inversion unnecessary.


ANÆSTHESIA.[87]

The importance of efficient anæsthesia during this operation is so
obvious that a few suggestions as to the best means of obtaining and
maintaining it will not be out of place. First, as to the choice of an
anæsthetic, the conditions of the operation are such that chloroform
seems the only agent which is conveniently applicable; our patients
moreover are generally children, and with such at any rate it may be
safely used. It has been recommended and practised by some to produce
initial unconsciousness by the administration of the A. C. E. mixture,
ether, or nitrous oxide gas, and then to maintain it with chloroform.
This plan is quicker, and supposed to be safer, but on either plea
the gain, if any, is so slight as to render the extra complication
undesirable.

As to the method of administering chloroform, the old plan of soaking a
piece of lint or towel with the drug and applying it closely to the air
passages until anæsthesia is produced ought by no means to be followed
in these days of advanced knowledge. It is well known that more than
4 per cent. of the vapour of the drug is dangerous, and hence a safer
method must be employed. All plans requiring the introduction of nasal
or buccal tubes are undesirable. The best method is that recommended and
always followed in the practice of my colleague, Sir Joseph Lister. The
corner of a well-starched towel fixed into a hollow oval by a safety pin,
sufficiently long to extend from the glabella to the point of the chin,
is kept continually moist by chloroform from a drop-bottle.

It is held close to the face without actually touching it; and when
complete anæsthesia has been induced can be held out of the way of the
operator, and yet sufficiently near for the patient to be still affected
by the drug. Any opportunity of inserting this adaptable mask into the
region of the mouth must be always taken advantage of by the anæsthetist,
so that as little delay and inconvenience as possible may be experienced.

During the operation a strict watch must be maintained upon the
respiratory functions, so that any laryngeal obstruction may be readily
noticed and treated. The colour of the pinna of the ear, the mobility
of the tongue, if unrestrained by a gag, and the condition of the
conjunctival and pupillary reflexes assist in giving useful indications
for an increased or decreased administration when the patient’s face is
obscured by hands, instruments, or congealed blood.

_When the conjunctival reflex is absent, and the pupil dilated and
unaffected by light, the anæsthetic should be temporarily suspended._

_When the conjunctival reflex is absent, the pupil contracted, and the
colour good, the patient is in the best condition of anæsthesia, and this
state should be maintained, if possible, throughout._

_When the conjunctival reflex is present together with dilatation of the
pupil, movements of the tongue, and other “reflex” efforts, the amount of
chloroform should be increased._

During the first stage of the operation, when hæmorrhage is profuse, deep
anæsthesia is undesirable for fear of blood passing into the larynx.
To prevent this, after the incisions have been made, sponge pressure
should be applied, and the head turned on one side. Any gurgling in the
throat, or dusky colour of the face, indicating threatening laryngeal
obstruction by blood-clot, needs an efficient application of a sponge on
forceps behind the tongue, the effect of this being not only to remove
blood, but also to stimulate closure of the glottis. The bleeding having
been arrested, and the later stages of the operation reached, a deeper
anæsthesia is necessary. Sudden increase or decrease of the amount of
the anæsthetic will readily induce vomiting, and if much blood has been
swallowed in the earlier stages, this _contretemps_ may be inevitable in
spite of all precautions.


DUTIES OF THE ASSISTANT.

For the efficient performance of the various steps of the operation a
skilled assistant is absolutely essential. His duties will consist, first
and foremost, in keeping the pharynx clear of blood; secondly, in such
dextrous use of sponges as will allow the parts to be clearly seen by
the operator; thirdly, in the judicious use of a tongue depressor, when
necessary; and fourthly, in exercising a careful supervision over the
stitches before they are finally fastened.

For the purpose of clearing the pharynx, he must be provided with a pair
of long smooth-nosed forceps (Fig. 61 B), and some small loose pieces
of purified sponge; or the sponges may be fastened on pieces of stick
about six inches long in such a manner and so securely that the necessary
manipulations shall not detach them. The former of these methods is, I
think, preferable.

The great art in clearing the pharynx consists in letting the sponge
slide over the dorsum of the tongue, and then by a rotary movement of the
wrist the clots are entangled upon its surface and easily removed. In
this manipulation the sponge should not touch the palatal structures more
than is absolutely necessary, as any friction or bruising of the edges
when pared is highly injurious. Vomiting, moreover, is readily excited by
too frequent sponging, especially about the uvula and soft palate.


INSTRUMENTS.

[Illustration: FIG. 57.—T. Smith’s gag with tongue plate (_Arnold_).]

[Illustration: FIG. 58.—Mason’s gag.]

[Illustration: FIG. 59.—Rose’s gag, double ended. Large end for adults;
small end for children. Sliding ring-catch fixing instrument in position.]

An efficient _gag_ is one of the most important requisites for a rapid
and successful performance of this operation. In the selection of such
appliances the choice will lie between those which merely separate the
jaws and those which, in addition, command the tongue. The latter are
represented by such as T. Smith’s (Fig. 57) or Whitehead’s gags; but
with either the tongue is apt to curl up at the back of the plate which
is intended to repress it, and severely embarrass, if not altogether
interfere with respiration, necessitating a hurried readjustment. Any
gag with a tongue plate is not only more difficult to adjust, but also
to remove in an emergency. I am inclined on the whole to think that
it is better to leave the tongue free, the assistant depressing it,
when necessary, with an ordinary spatula. The apparatus should be as
simple as possible, unilateral, and easily moved from one side of the
mouth to the other, and constructed with a minimum amount of metal and
projections which might obscure the field of operation, or cause delay by
entanglement of the stitches. These conditions are, I believe, fulfilled
as nearly as possible in my own adaptation of the late Mr. Francis
Mason’s gag, generally used by Sir Wm. Fergusson (Figs. 58 and 59). As
will be seen from the drawing, the gag is unilateral, provided with a
sliding ring-catch easily thrown in and out of position, and so made
that by reversing ends it can be used either for an adult or a child.
The portions inserted between the teeth are covered with rubber tubing
or fine twine, thus protecting them from injury, and in some measure
preventing the gag from slipping. I admit that the supervision of an
assistant is needed to maintain its position, but contend that this is
rather an advantage than otherwise, and the breathing is less likely to
be interfered with. It is inserted closed between the lateral incisors,
and is gently pushed back until between the molar teeth, when it is
opened to a sufficient extent, and fixed in that position by the sliding
catch.

[Illustration: FIG. 60.—Various forms of raspatories employed in
detaching the muco-periosteal flaps in uranoplasty. The three in the
left-hand lower corner are used for detaching the flaps anteriorly (After
_Durham_).]

[Illustration: FIG. 61 A, B, C.—Fine hook forceps. Long smooth-nosed
forceps. Knife for paring the edges of the cleft (_Mason_).]

A small scalpel, raspatories of various shapes, right and left-handed
(Fig. 60), long smooth-nosed, and fine hooked forceps, and a
long-handled, narrow-bladed, very sharp paring-knife (Fig. 61) are
necessary. For seizing the edge of the cleft in order to remove the
mucous membrane therefrom, the surgeon will find the forceps depicted
in Fig. 62 extremely useful; they are an adaptation of a pair of German
trachelorraphy forceps, and possess the following advantages: first, by
their angular prehension they can seize the exact edge of the palate, and
then when seized, the hold is maintained by means of a spring catch in
the handle. It is obvious that a pair of straight hooked forceps (Fig. 61
A) introduced into the mouth cannot so certainly seize the edge, whilst
the slightest relaxation of the fingers causes it to loose its hold.

[Illustration: FIG. 62.—Angular long-handled catch forceps (the teeth are
a little coarser than in the original).]

[Illustration: FIG. 63.—Various forms of needles employed in palate
operations. The left-hand figures show the double-curved needles used in
suturing the uvula.]

The _needles_ best adapted for this work deserve a somewhat detailed
description, inasmuch as the clumsy forms generally in use twenty
years ago have been superseded by much more satisfactory and delicate
instruments, which inflict less injury in passing through the palatal
structures. Those most commonly employed are a special modification of
the Hagedorn type of needle (Fig. 63), long, narrow, measuring with the
handles about eight inches, fine, curved, and flattened laterally, with
a small eye near the point, and so ground and set that there is only
a short cutting edge on the convex side close to the extremity. The
advantage of this is that when introduced quite close to the edge of the
palate, its blunt concave border directed towards it has no tendency to
cut its way out, whilst the convex cutting edge makes a track for the
needle and suture to follow. It is manifest that the incision thus made
is at right angles to the margin of the cleft, and consequently when the
suture is drawn tight, the tendency is rather to close than to open the
needle track. With the old needles making as they did in their passage
an incision parallel with the edge of the cleft, the tightening of the
suture caused the opening to gape, and this occasionally resulted in the
establishment of a fistulous aperture leading to subsequent trouble.
(Compare Figs. 64 and 65.) Mr. T. Smith emphasised this point as far back
as 1868. (_Vide_ an interesting paper of his in ‘Med.-Chir. Trans.,’ vol.
51.)

[Illustration: FIG. 64.—Shows effect of drawing stitches together when
needles cutting parallel to the edge of the cleft have been used,
resulting in an oval opening at the site of each needle puncture.]

[Illustration: FIG. 65.—Contrasts the effect produced when needles
cutting at right angles to the cleft margin are used. There is no
tendency to opening up of the needle tracks, but rather to close them.]

With reference to the _sutures_, many different materials have been
employed, such as silk, silkworm gut, catgut, horsehair, and fine silver
wire. For many reasons the silver wire is to be preferred; it can be
more easily and accurately adjusted to the required degree of tension,
and has no tendency to slip; catgut and horsehair are often so springy
that the knots are liable to come unfastened. Silver wire is less
irritating, and therefore can be left for an almost indefinite period _in
situ_; it is incapable of absorbing septic material, and is insoluble in
the tissues. The method of introducing the wire stitches is described
later (p. 119); the wire twister (Fig. 66) will be found useful for the
purpose of regulating their tension.

[Illustration: FIG. 66. Wire twister (_Maw_).]

The thickness of the wire used must vary directly with the delicacy or
otherwise of the palatal tissues; the thinner the palate, the finer the
wire, and _vice versâ_. In different portions of the same palate, wires
of varying thicknesses have often to be used. The principal varieties
that I make use of are Nos. 30 and 32 on the ordinary wire gauge.
Whichever is used, it should be uniformly and well annealed, otherwise it
is liable to break whilst being twisted, and does not straighten out on
removal. In the region of the uvula it is better to employ some softer
material, such as fine silk or catgut, as the projection of the ends of
the wire has a tendency to irritate the back of the tongue and cause
coughing and nausea.

A narrow straight probe-pointed bistoury may be needed to extend the
lateral incisions into the soft palate, in order to relieve lateral
tension.


THE OPERATION.

It will be convenient first to describe in detail the technique of
the operation in a typical case of combined cleft of the hard and
soft palate, _i. e._ the operations of uranoplasty and staphyloraphy
combined, and subsequently indicate the modifications necessary under
special circumstances.

The method which is now almost universally employed is that known as
Langenbeck’s, effecting complete closure by dissection of muco-periosteal
flaps obtained from either side of the cleft, and sutured in the middle
line. Although called after the great German surgeon, and rightly so,
inasmuch as he first clearly enunciated the principles underlying the
operation, it is certain that similar plans had been previously employed
by others. The late Mr. Avery, of Charing Cross Hospital, seems to have
been the first in this country to completely close a cleft in the hard
palate, and he employed and described[88] a method very similar to
Langenbeck’s. This was undertaken in 1848, and in 1853 Messrs. Weiss
made improved and special raspatories for the operation. Langenbeck’s
paper, on the other hand, did not appear until 1862. Previous to this
various plans of surgical treatment had been employed. Operations upon
the soft palate were undertaken much earlier than upon the hard, and
although priority has been claimed both for Prof. Graefe[89] (1816) and
M. Roux[90] (1819), who performed staphyloraphy independently, yet it
is certain that a similar proceeding had been adopted by others in the
latter half of last century. The first reference to a successful case
that we possess is in 1760, when a dentist named Lemonnier[91] united
the borders of a cleft in a child. Desault and others record similar
cases in the first decade of this century. As regards the hard palate,
M. Krimer[92] seems to be the first who attempted operative treatment
(1824); he dissected up small muco-periosteal flaps on either side of
the cleft, reversed them from without inwards, and united them in the
middle line by sutures. M. Beaufils made use of a single flap twisted on
itself so as to fill the aperture. Dr. Mason Warren in 1843 published
a method of operating which seems in his hands to have been moderately
successful, although only after repeated operations. He dissected up the
mucous membrane, and freed the soft palate by dividing the posterior
pillars with strong curved scissors, and then sutured in the median
line. Several methods of “bony suture” have also at different times been
suggested. Dieffenbach[93] led the way in 1826, and was followed by many
other surgeons, Fergusson and Mason being prominent amongst them in this
country. But the results were never satisfactory, and the method has now
been entirely superseded by Langenbeck’s operation, which is applicable
in almost all cases.

It may be divided into four stages:—

Stage 1. Incision, and detachment of muco-periosteal flaps.

Stage 2. Paring the edges of the cleft.

Stage 3. Passage and tightening of sutures.

Stage 4. Relief of lateral tension.


STAGE I.—_Incision and Detachment of Muco-periosteal Flaps._

The patient being thoroughly anæsthetised, and the mouth held open
by the gag, the surgeon, standing on the right side of the patient,
commences by making a lateral incision, preferably on that side of the
cleft which is opposite to the gag; it facilitates matters to shift the
gag to the opposite side of the mouth when the second incision is made.
These incisions should commence a little internal and opposite to the
last molar tooth (Fig. 67 A), and should be carried forward parallel to
the alveolar margin to a point immediately behind the lateral incisor,
terminating a little anterior to the apex of the cleft, if the alveolus
be intact. The knife should be held so that the incision is always
perpendicular to the varying planes of the mucous membrane, in order to
prevent the edge from being bevelled, which may seriously impair its
nutrition. All the structures should be cleanly divided down to the bone.

[Illustration: FIG. 67A.—Diagram to indicate the extent of the incisions
in Langenbeck’s operation. The thick black lines show the primary
incision; the thick dotted lines the extension backwards of the same to
relieve any lateral tension (made after the insertion of the stitches);
the thin dotted lines indicate approximately the position of the free
posterior border of the bony palate.

FIG. 67B.—Shows the position of the sutures and the condition of the
parts at the close of the operation.]

Hæmorrhage, even to a considerable amount, naturally follows, and this
should be checked by pressure with purified sponges; it will be much more
serious should the palatine arteries be included in the line of incision.
The distribution of the anterior and posterior palatine arteries is so
variable, and their pulsation so rarely to be felt beforehand, that it
is not always possible to avoid wounding one or other of them. Should
this occur, it is important that the vessel be _completely_ divided, as
a buttonhole in it will cause severe and protracted hæmorrhage. During
the bleeding the patient’s head should be turned on one side and lowered,
so as to allow the blood to run freely out of the mouth and not into the
throat.

Whilst the assistant is staunching the hæmorrhage, the operator can
introduce the raspatories through the openings thus made, and working
them _from without inwards_, separate the whole of the muco-periosteal
tissue. To effect this, different shapes of instruments will be required
in order to follow the curves of the palatal segments, and those devised
by Mr. Durham will be found most useful (Fig. 60). In loosening the
flaps anteriorly, the advantage of the double-curved raspatory (Fig. 68)
will be obvious. As the point of the raspatory reaches the inner free
margin of the palatal segment, the separation of the muco-periosteal flap
should be completed by the protrusion of the instrument into the cleft
at the junction of the buccal and nasal mucous membranes. This is more
readily accomplished if the edges have been previously pared; but it is
better to postpone this step until the flaps have been detached, as the
raw edges are less liable to be bruised by the sponging, and with the
flaps loosened the margin can be pared with greater accuracy. In cases
where the vomer is attached to one free edge of the palate (Fig. 11) the
junction of the nasal and buccal mucous membrane should be incised to
prevent its being lacerated by the raspatory.

The attachment of the soft structures to the hamular process and back
of the hard palate must be freely and fully divided. This is a most
important and delicate part of the operation, and as the structures are
here extremely thin, great care must be exercised. Should this separation
be incomplete, the lateral incision cannot be carried down into the soft
palate, and the flaps will not come into proper apposition. It may be
attained by the use of a sharp cutting raspatory kept close to the bone,
and as regards the hamular process, by a narrow probe-pointed bistoury,
or a pair of curved scissors. The introduction of the left forefinger
into the incision is of great assistance in effecting this with precision
and thoroughness.

[Illustration: FIG. 68.—Double-curved raspatories for detaching the
anterior portion of the muco-periosteal flaps in uranoplasty.]

After detachment the muco-periosteal flaps will often appear blanched
or of a bluish-white colour as a result of the interference with the
circulation, a fact which has been commented on by M. Trélat. The
circulation, however, is soon re-established, and the normal colour
returns in a few hours.

When this proceeding has been satisfactorily accomplished on both sides,
a temporary delay generally occurs for the assistant to arrest the
hæmorrhage, and for the anæsthetist to get the patient more fully under
control, so that the second most important stage may be conducted without
any struggling.


STAGE II.—_Paring the Edges of the Cleft._

The extreme inner edge of the cleft velum should be seized near the base
of the half uvula with the catch forceps (Fig. 62). The narrow-bladed
knife (Fig. 61C) is entered with the back towards the tongue, just
in front of the forceps, and made to cut the merest shaving from the
margin as far as the apex of the cleft. Before relaxing the grasp of
the forceps, the same process is continued backwards to the apex of
the half uvula. The other side of the cleft is similarly treated, and,
if possible, the strip of marginal tissue removed should be continuous
throughout, thus satisfactorily proving that the whole of the cleft
has been pared. This strip should be cut square with the palate, for
if bevelled, the edges cannot afterwards be brought into such accurate
apposition.

Care should be taken in this proceeding not to contravene the important
canon of plastic surgery, that no unnecessary amount of tissue should be
removed; for it is most important to remember that in these cases, there
is no excess of material, and that a too free removal of marginal tissue
will lead to increased tension in the united palate, and subsequently
to a less satisfactory functional result from defective closure of the
posterior nares.


STAGE III.—_Passage and Tightening of Sutures._

The quickest method and the one calculated to disturb the parts the
least is a modification of that introduced and practised by the late
Sir William Fergusson, the so-called “loop-method.” It consists in the
passage of a loop of fine silk through both sides of the cleft, to act as
a carrier for the silver wire which is to be the permanent suture. One
of the needles already described, previously threaded with a piece of
fine silk about sixteen inches in length, so that its ends are equal, is
passed from the buccal aspect through the loose flap close to the margin
of the cleft (_i. e._ about 2 or 3 mm. from it), and as near as possible
to its anterior extremity. To accomplish this it is unnecessary to hold
the flap with forceps, as its margin may be seriously damaged. The needle
track should be perpendicular to the palate surface, and therefore
parallel to the pared margin of the cleft. The silk is then seized
close to the eye of the needle with the smooth-nosed forceps introduced
within the cleft, the needle withdrawn, and the loop pulled forwards
sufficiently to be laid temporarily on the side of the cheek. The same
process is repeated at an exactly corresponding point on the opposite
side, so that now there are two loops emerging from behind forwards
through the cleft. By loosely threading the right loop through the left
and gently withdrawing the latter, the former is carried through the flap
on the left side (Fig. 69); in this way we have a double thread, with its
loop on the left side and its free ends on the right, passing through
the flaps on either side. This process is repeated at intervals of about
5 to 6 mm. throughout the length of the cleft from before backwards,
until the uvula is reached, the anæsthetist and assistant guarding the
loops and ends of the silk by placing their hands on them at the sides of
the face. This is especially needed if much sponging is called for, or if
vomiting occur. The uvula need not be dealt with until the silver sutures
have been tightened.

[Illustration: FIG. 69.—Loop method of passing sutures in palate
operations. (_Mason._)]

The silver wire must next be substituted for these loops, and this is
effected by taking a six-inch length of the former and doubling half an
inch of one end into a hook over the loop; gentle traction on the free
ends of the silk will easily draw the wire through into its place. A
small piece of sponge lightly dabbed on the edges of the cleft at the
point of suture removes any adherent blood-clot or mucus. The ends of
the wire are crossed and the wire-twister (Fig. 66) applied, and in
this way the suture is tightened until the margins of the cleft lie
accurately in apposition, without undue mutual pressure or folding in of
the edges; experience and practice can alone decide the requisite amount
of tension. When this has been accomplished, the twisted ends are cut
off with scissors, leaving a sufficient length visible to allow of easy
removal when necessary. It is better to deal in this way with each wire
separately, in order to prevent entanglement or confusion.

To stitch the uvula, a double-curved semicircular needle (Fig. 63) may be
advantageously employed, and passed through both sides before withdrawing
it; as previously stated, no substitution of wire is advisable (p. 114),
but the silk is drawn tight by means of a slip-knot made fast in the
usual way (Fig. 70). Two of these silk sutures may often with advantage
be inserted in the uvula, but this should be accomplished with the
greatest possible delicacy of manipulation, as any rough handling with
the forceps may result in bruising, œdema, and subsequent non-union. The
sutures, moreover, must be so placed that the circulation in the uvula
is not interfered with when they are drawn tight, or strangulation and
sloughing may follow.

[Illustration: FIG. 70.—Method of tying slip-knot for uvula stitch;
formerly used in each suture. (_Fergusson._)]

[Illustration: FIG. 71.—T. Smith’s palate needle (_Arnold_).]

Although the above detailed process appears very elaborate, it certainly
seems to me the best. Other methods are used by many, and amongst these
perhaps the most frequently employed is the “direct” method of Mr. T.
Smith. In this the needle (Fig. 71) is double-curved and hollow, and
the wire which is wound on a drum in the handle of the instrument can
be projected at will from the aperture at the point by a movement of
the thumb. Different shapes are used for different parts of the palate.
The needle is passed from below upwards through one side of the cleft,
and without withdrawing it through the other from above downwards; the
wire is now protruded from the point of the needle, grasped by forceps,
paid out from the drum, and the needle withdrawn as it entered. Mr.
Smith’s usual practice is to stitch from the uvula upwards, tying each
stitch as it is inserted, and making use of the ends of one stitch to
steady the palate whilst introducing the next. The advantage claimed
for this method, viz. the saving of time, is more than counterbalanced
in my opinion by the following drawbacks; first, the strain exercised
upon one of the palatal flaps in order to pass the needle through the
other; second, the occasional and not infrequent hindrances to the smooth
working of the wire by its kinking; and, thirdly, the difficulty often
experienced in seizing the end of the wire.


STAGE IV.—_Relief of Lateral Tension._

The palate having been thus satisfactorily sutured, the relief of lateral
tension and the division of the levator palati have now to be undertaken;
for however well the parts may appear to lie, it is never safe to omit
this. A narrow-bladed probe-pointed bistoury is introduced through the
lateral aperture on either side, and carried directly backwards through
the soft palate. It is useful to introduce the left index finger into the
lateral opening to ascertain if any fibres of the muscle still remain
undivided. This plan was first introduced and practised by Mr. Pollock in
mild cases of cleft palate, where the fissure extended through the velum
only.

It may not be out of place to notice the method adopted by Sir W.
Fergusson for dividing the levator. A triangular-bladed knife set at
right angles to a long stem was introduced behind the velum, and the two
edges of the angular point made to cut their way between the pterygoid
plates down to the bone, so as to divide the muscle close to its origin.
From a theoretical point of view this appears all that can be desired;
but practically the results following this procedure were not always
satisfactory, inasmuch as the tension upon the stitches often appeared to
be but little relieved, and one could never tell with certainty whether
the muscles were effectually divided or not; in addition to which, unless
the surgeon were very skilled in the use of the instrument and the
anatomy of the region in which he was cutting, serious mischief might and
did sometimes ensue. A knife such as the one to be employed, cutting at
right angles to the handle, can never be used with absolute precision,
particularly when the part to be dealt with is out of sight. The ease and
certainty with which the structures can be divided by the former method
of prolonging the lateral incision backwards have rendered this plan of
Fergusson’s obsolete, although in his hands it was often very successful.

Should the hæmorrhage from these final incisions made in the soft palate
be excessive, steps should be taken to ascertain whether the trunk or
any large branch of the posterior palatine artery has been partially
divided, as if so the bleeding is liable to recur at intervals, and may
become serious. Under such circumstances, complete division of the vessel
has almost always the immediate effect of staying the hæmorrhage. Sponge
pressure and syringing with iced boracic lotion may be useful adjuncts
in arresting the general oozing; but long continuance of the latter is
detrimental to the vitality of the flaps and may endanger primary union.
For a similar reason, plugging the lateral apertures, or recourse to
powerful styptics, such as perchloride of iron, should if possible be
scrupulously avoided.

All lateral tension being now relieved, and no serious hæmorrhage
continuing, the sutured palate should present a solid, if somewhat
blanched appearance in the middle line; the gag can be removed and the
operation is complete.

Thus far we have been describing the operative treatment in the severer
forms of cleft, in which both hard and soft palate are involved.
When, however, the velum alone is cleft, merely the operation of
_staphyloraphy_ is required. In such cases the lateral incisions need not
be of such an extensive character, and are usually made after the edges
have been pared, and the stitches passed. It was for this type of case
that Mr. Pollock introduced his method of dividing the levator palati by
entering the knife through the mucous membrane of the velum a little in
front and to the inner side of the hamular process, which can be felt
in the mouth just behind the last molar tooth. The knife is pushed
through the substance of the palate, and then by raising the handle and
depressing the blade the muscle can be fully divided without making too
extensive an incision in front. I should strongly recommend, however,
a sufficient incision being made to admit the tip of the index finger,
in order to ascertain with certainty that no tense fibres of the muscle
remain undivided.

When the uvula alone is cleft no lateral incisions are necessary.

When the cleft extends for a short distance into the hard palate, lateral
incisions must be made in the first stage of the operation, extending to
a point a little anterior to the apex of the cleft, for the purpose of
introducing raspatories to loosen the soft tissues around this point.

In some cases, after the soft palate has been brought together, a certain
amount of tension is observed to be exercised upon the flaps by the
traction of the muscles in the pillars of the fauces. If this be so, they
should be divided by snipping them across with a pair of blunt-pointed
scissors curved on the flat. By this means lateral tension is diminished,
and the velum can be subsequently more easily approximated to the
posterior pharyngeal wall.


MANAGEMENT OF THE PATIENT AFTER OPERATION.

The patient should be placed in bed with the head low and no pillow,
so that any oozing or accumulation of mucus, whether from the upper or
lower surface, may gravitate into the pharynx; otherwise it may insinuate
itself between, and tend to separate the lips of the wound.

A certain amount of shock is frequently observed during this period,
and the circulation in the extremities should be promoted by warmth. A
shivering fit, scarcely amounting to a rigor, is often observed, but
is of no prognostic importance. During reaction, the blood which has
been swallowed during the operation is usually vomited; when this occurs
early the danger to the palate is not very great; but any vomiting at
a later period has a serious disturbing effect, and the greatest care
must be exercised in the supervision of the diet and general hygienic
surroundings in order to prevent such accidents.

_Diet._—It is best to give no nourishment for the first three or four
hours, and but very sparingly for the first twenty-four. Iced milk and
water, or milk and soda-water, given in small spoonfuls, should be the
first food supplied; but after twenty four hours, when the tendency to
vomiting has disappeared, the food should be slightly warm. Milk and
water given by spoon or from a feeder at frequent intervals will form the
staple article of diet; but if the patient be rather older, strong broths
and clear soup may be added. By the fifth day they may often safely take
soaked bread, custard pudding or some soft farinaceous food; but no hard
substance, liable to damage the newly-formed adhesions, should be allowed
for fully a fortnight.

If the patient be sufficiently intelligent, it is advisable that the
_mouth_ should be gently _washed out_, especially after food, with a
tepid weak boracic solution. This is best effected by using it as an
ordinary gargle; syringing the mouth I consider to be unadvisable,
because the jet if forcible will tend to find its way between the margins
of the wound, and hinder union. Some surgeons recommend that prior to
fastening the stitches during the operation, the edges of the wound
should be touched with a solution of chloride of zinc in order to assist
in keeping them aseptic; this is really unnecessary if careful washing of
the mouth after the operation be enjoined.

Of course _absolute quiet_ is essential, and all attempts at talking
must be strictly forbidden. The child should be closely watched, and
any attempt to meddle with the palate should be prevented by tying down
the hands, which may be done as a matter of precaution throughout the
whole duration of the case with young children, and as a routine during
sleep with all patients. If the child is noticed to suck at the palate,
or curl the tongue up against it, an effort should be made to divert its
attention.

The palate should not be examined too often. The blanched appearance
observed at the close of the operation generally disappears during the
first few hours, and a moderately injected condition of the mucous
membrane with slight swelling of the palatal tissues is a sign that all
is doing well. The lateral incisions usually fill with granulations
rapidly, and these subsequently cicatrise; the rate of their healing
depends on the width of the aperture and on the vitality of the patient.

It is impossible to lay down any hard and fast rule as to the period
when the stitches should be removed. In the majority of cases where the
course has been satisfactory the stitches in the velum may be safely
removed on the sixth or seventh day; those in the hard palate, if causing
no irritation, had better remain a little longer. If there is any doubt
as to the firmness of the union, the sutures should not be touched
till later, as they seldom of themselves give rise to any trouble. It
occasionally happens that a child refuses to open its mouth, and renders
removal of the stitches without the chance of damaging the palate
impossible; an anæsthetic must then be administered.


AFTER-COMPLICATIONS.

In spite of every precaution taken both at the time of the operation and
subsequently, it occasionally happens that the process of repair does not
proceed satisfactorily.

This is mainly due either to a low state of vitality on the part of the
patient, or to the development of some febrile or catarrhal condition,
or to a septic contamination of the wound. Cases have occurred in which
diphtheria, measles, or scarlet fever have shown themselves a few days
after the operation, and, under such circumstances, there is a great
probability of complete failure of union, the stitches ulcerating
through, and even a portion of the soft palate being destroyed by a
necrotic process. Such a result, however, does not necessarily ensue, for
in one of my cases good union was obtained throughout the greater part of
the palate in spite of an attack of measles.

In the majority of instances where defective union occurs there has been
some neglect in the observance of the precautions upon which stress has
been laid above. The most common errors are as follow:

_a._ Inefficient relief of lateral tension. Of late years I have become
more than ever convinced of the paramount importance of the use of free
incisions, and also that the vascular supply of the palate is amply
sufficient to allow of these being made without any danger of sloughing,
or of hindering primary union. That sloughing has occurred in the
practice of others is undoubted; but this is more likely to have been due
to a septic contamination and bruising of the tissues than to the extent
of the incisions. I would again refer my readers to what has been already
written (p. 118) as to the separation of the palatal tissues from the
hamular process, and the complete detachment of the muco-periosteal flaps
from the point of junction of the hard palate with the soft, where the
tissue is thinner than elsewhere.

_b._ Defective paring of the edges of the cleft. This probably occurs
from want of skill on the part of the surgeon, who fails to remove in one
strip the mucous membrane from the margins.

_c._ Bruising of the edges from careless sponging, or rough manipulation
with clumsy instruments. This is particularly liable to occur if the
edges are pared prior to the detachment of the muco-periosteal flaps, in
accordance with the mistaken directions given in many text-books.

_d._ Inaccurate coaptation of the edges of the wound, caused either by
the stitches not being inserted at exactly opposite points on either
side of the cleft, or by bringing the edges together too loosely, or so
tightly that they are curled in.

_e._ Incomplete division of the levator palati will possibly explain some
cases of non-union of the soft palate.

_f._ Want of careful supervision after the operation, and unsuitable food.

_g._ The occasional occurrence of uncontrollable vomiting or excessive
hæmorrhage.

The most frequent situation of defective union is at the point of
junction of the hard and soft palate; the tissue here is extremely thin,
and laceration is liable to occur during the detaching process.

The apex of the cleft is another likely spot where union may fail; here
from rigidity of the tissues accurate apposition is rendered difficult
and sometimes impossible, particularly when the deformity is associated
with alveolar cleft.

When apertures have resulted from any of the above detailed causes, it
is useless to attempt to close them immediately, and moreover subsequent
cicatrisation may much diminish their size or even close them entirely.
M. Trélat[94] has seen one 9 mm. in diameter thus disappear, and my
experience fully confirms such an observation. When, however, the
contraction has come to a standstill, the margins may be pared, the
lateral apertures reopened, the tissues loosened again from the bone, and
the opening closed by as many sutures as may be necessary. Small fistulæ
are often cured by the application of lunar caustic or fuming nitric acid.

Occasionally some trouble is experienced in the closure of the lateral
apertures, one or both of them remaining patent and threatening to become
fistulous. As a rule no anxiety need be entertained on this score. The
only case in which I have had trouble was in a severe complete cleft in a
young woman of twenty-seven; one of the openings was only closed twelve
months after operation by applying nitric acid.

The occurrence of _secondary hæmorrhage_ may be of so severe a character
as to give rise to great anxiety, and it, as well as the treatment
adopted for its arrest, may seriously interfere with the process of
repair. Both intermediary and secondary hæmorrhage are met with; the
former generally ceases after the application of cold, and seldom
requires more active treatment. If, however, it arises from a large
vessel such as the posterior palatine, which may have been incompletely
divided, the re-introduction of the bistoury to complete the division
and allow the artery to retract and subsequent sponge pressure will be
necessary. In cases of true secondary hæmorrhage the palate wounds have
probably progressed satisfactorily up to the fifth or seventh day, when
suddenly there is an alarming gush of blood from one of the lateral
apertures, and the patient becomes blanched and faint. The lateral
apertures should be at once carefully syringed out, and the source of
the bleeding discovered, if possible; the patient should lie with the
mouth open and the head supported on a pillow. The use of styptics, such
as perchloride of iron, should be studiously avoided, and, if absolutely
necessary, I infinitely prefer to use the galvanic or Paquelin’s cautery.
Some (_e. g._ Howard Marsh) have recommended and practised searching for
the posterior palatine canal with a probe, and plugging it with a piece
of wood, but of this I have had no experience. Although the bleeding may
cease for a time it is liable to recur; under such circumstances it is
best to enlarge the lateral apertures in order to expose the source of
the hæmorrhage, which can then be dealt with as needful. Plugging of the
lateral wounds should be reserved as a _dernier ressort_ for fear of
pressing injuriously upon the new vessels in the recent median cicatrix.
These plugs, whether of lint, gauze, or sponge, soon become septic and
sources of danger, and cannot therefore be long retained, whilst removal
is liable to be attended with fresh bleeding.


MODIFICATIONS OF THE OPERATION.

The operation of _osteoplasty_ demands a brief notice under this heading.
It was first practised by Dieffenbach in 1826, and subsequently revived
in 1874 by the late Sir William Fergusson, whom I had the privilege of
assisting in some eighty cases.

The principle of the operation consisted in carrying each lateral
incision through the bony palate by means of a chisel, and prising the
detached portions towards the middle line. Prior to this, however, the
edges of the cleft were pared, and sutures were passed through holes
previously drilled in the bony margins. The intention was to secure
the union of flaps containing bone in the median line. Unfortunately,
the results were anything but satisfactory, for in many instances the
detached portions became necrosed and set up active inflammation and
suppuration, leading to non-union. The bone, moreover, did not always
cleave in the desired direction, and although the late Mr. Mason
endeavoured to obviate this by punching holes, as a preliminary step,
along the line the chisel was subsequently to take, on the postage-stamp
principle, the results were not improved. One great objection to this
lies in the difference of level which often exists between the two sides
of the palate, especially when the vomer is attached to one margin. It
is then excessively difficult to get the detached segments accurately
together, whereas in Langenbeck’s operation the muco-periosteal flaps
drop readily into position. Consequently, this method of osteoplasty has
long since fallen into disuse.

In cases where the vomer is attached to either side of the cleft with a
wide gap and scanty tissues, Mr. T. Smith has suggested the utilisation
of the mucous membrane covering the vomer as a means of bridging the
cleft. He incises it in a direction parallel to the edge, and at such
a distance above the palate margin as is thought advisable; detaches
it from above downwards by a hooked raspatory, and stitches it to the
pared margin of the opposite side. Owing to the extreme delicacy of
the membrane in this situation and the tendency it has to curl up, the
success of this manœuvre is not always to be assured.

Mr. Davies-Colley has recently published[95] an account of an operation
for which, indeed, he does not claim superiority over the usual method
of closing ordinary clefts in the hard and soft palate, but which, he
urges, should be adopted in the following contingencies—(1) for infants,
(2) when the ordinary operation has failed, and (3) when the cleft in
the hard palate is very wide. It consists in dissecting up a triangular
muco-periosteal flap from one side of the cleft and entirely detaching
it anteriorly, its base being at the junction of the hard and soft
palate. On the other side a raw surface is prepared for its reception by
reflecting a longitudinal flap of muco-periosteum in such a way that it
can be turned as on a hinge into the cleft, and maintained in position
there. The loose flap is then planted on it, and fixed by sutures. A
bridge is thus formed across the hard palate consisting of a double
muco-periosteal flap. The advantages claimed for this operation are
less hæmorrhage, double thickness of flap, no loss of tissue, absence
of tension, and that upward pressure of the tongue is more likely to
do good than harm, whereas in Langenbeck’s the reverse is the case.
There are obvious disadvantages, in particular that the hard palate is
alone united, and that a foramen at the front part of the cleft usually
remains; and although in Mr. Colley’s hands it may be occasionally
successful, it scarcely appears to be one adapted for general use. As to
its applicability in the case of infants, it is probably a procedure not
devoid of risk, inasmuch as no operation can be safely undertaken in the
majority of cases before the age of three years. The reader is referred
to p. 101 for my reasons for this. When an operation has failed, it is
surely more advisable to attempt closure of the whole cleft by repeating
Langenbeck’s method rather than by a proceeding admittedly incomplete at
first and requiring further treatment. When the cleft is wide anteriorly,
it must be conceded that ordinary uranoplasty is often not sufficient
to effect at one operation complete closure, and an anterior opening
is not unlikely to persist, a condition, however, which Mr. Colley’s
operation in no way prevents. My own practice, under such circumstances,
is to obtain union as far forward as possible at the first operation,
and to deal subsequently with the fistula by a modification of the same
proceeding.

When a triangular opening has been left in front, owing to absence or
previous removal of the os incisivum with the maxillæ more or less widely
separated by a gap which extends anteriorly to the mucous membrane of
the lip, it is often impossible to bring the edges of the cleft together
however freely the raspatory is used, and many plans have been devised to
meet this very definite difficulty.

Some surgeons have detached one muco-periosteal flap anteriorly, and so
been able to bring it across the cleft and stitch it to the opposite
side. But the interference with the vascular supply to the apex of the
flap, and the rapid shrinkage which is apt to take place, frequently
make matters worse than before. My experience of this plan has not been
satisfactory.

Another method that I have recently employed with partial success
consisted in reflecting a flap of mucous membrane from the back of the
upper lip, and turning it down into the gap, fixing it laterally to the
refreshed margins by fine wire sutures. Even if complete union does not
take place, the portion thus reflected forms a _point d’appui_ for later
plastic interference.

It has also occurred to me to try the effect of cutting through the
alveolar process immediately external to the canine tooth; that is,
instead of detaching the palatal flap anteriorly to continue the lateral
incision forward through the bony alveolus and after partially detaching
this to prise it towards the median line. This proceeding is practically
a modification of Fergusson’s osteoplasty, but differs from it inasmuch
as there is little fear of necrosis on account of the spongy and vascular
state of the alveolus. In the performance of it, after the palatal flaps
have been detached by the raspatory, I incise the gum vertically along
the line indicated, that is, continuing the lateral incision forward
external to the canine tooth; a notch is then made with a small saw, and
a chisel inserted cuts through and sufficiently detaches the portion
of the alveolar process contiguous to the palate. The edges are now
carefully freshened, and, if necessary, on the bevel, so as to allow for
the slight rotation which occurs in drawing them together. Sutures are
passed through the soft tissues deep enough to gain a firm hold of the
flaps, so that when twisted they do not cut their way out in spite of
the traction which is exercised. Care must be taken to pass the stitches
in such a manner as to prevent undue rotation of the detached portions,
otherwise the raw edges will not come into proper contact. Having at
present given this plan but a limited trial, I do not wish to speak too
confidently in its favour. Should such operative proceedings fail, an
obturator should be fitted to the aperture.

Many other methods have been from time to time suggested as accessories
to the ordinary operations of uranoplasty and staphyloraphy, and
some of these need a cursory notice. Passavant stitched the halves
of the velum to the posterior pharyngeal wall by an operation, known
as “staphylo-pharyngoraphy.” Schönbein and Trendelenburg suggested
“staphyloplasty” as an improvement, _i. e._ taking a flap of mucous
membrane from the posterior pharyngeal wall and stitching this to the
hinder wall of the velum. Both these operations aimed at totally shutting
off the nose from the mouth; but in practice this was found to be not
only uncomfortable, but also injurious. Smell and hearing were both
interfered with, and breathing could only be carried on through the
mouth; actual inflammatory troubles followed, which necessitated the
communication being reopened.

Von Mosetig Moorhof attempted to improve upon these operations by
allowing a fistula to remain at the position of the anterior palatine
canal, which could be filled with an obturator by day to prevent the
objectional nasal twang, and at night could be left open for breathing
purposes.

Still more heroic are the operations which have been undertaken for the
closure of palatal clefts by tissue taken from the face. Only three such
cases, are, I believe, on record and of these two were for acquired
deformities, and but one was for a congenital deficiency.

Blasius operated in a case where both the nose and the palate had been
destroyed, by dissecting up a flap from the forehead attached to a long
pedicle. This he easily twisted down into the mouth owing to the absence
of the nose, and stitched into the gap. Success, however, did not follow
from the drying effect of the double current of air. The same method was
tried on the cadaver by Nussbaum, who demonstrated the possibility of
drawing the flap through a slit in the nostril into the mouth and fixing
it there; but he never had the opportunity of operating upon the living
subject.

Professor Thiersch in 1868 successfully closed a hole in the hard palate,
the result of a gunshot injury. He chiselled away the alveolar process,
and turned in through this a flap consisting of the whole thickness of
the cheek, its base being close to the nose.

Rotter records a third instance.[96] It was in a case of very wide
right-sided harelip with cleft palate, in which Langenbeck’s operation
had been successfully performed in so far as union in the middle line
was concerned but the left palatine process was so nearly vertical that
a lateral cleft half an inch in breadth resulted. This was repaired by a
modification of Blasius’ operation. A long cutaneo-periosteal flap was
taken from the forehead; the raw under-surface was grafted and allowed
to heal entirely before being placed _in situ_. To accomplish this it
was merely necessary to draw it through the still unclosed harelip to
pare the edges of the flap and of the cleft, and to fix with sutures the
former within the latter. When united firmly, the pedicle was divided,
and the harelip closed. A good result followed, and was maintained two
years later.

Such procedures can only be necessary in exceptional cases. Permanent
scarring of the face is always to be regretted, and Langenbeck’s method
or some slight modification of it, carefully and skillfully carried out,
should meet nearly all contingencies. There is an instance recorded
by Wolff[97] where the whole of the right-sided flap in a case of
uranoplasty became gangrenous, leaving a wide opening which, however, was
successfully closed subsequently by a repetition of the same process.




CHAPTER VII.

ON OBTURATORS AND ARTIFICIAL VELA.


Before the year 1830, when operative treatment for the closure of
cleft palate first attracted attention, and began to be recognised as
a legitimate surgical procedure, the only means of alleviating the
troublesome symptoms resulting therefrom was by the use of artificial
mechanical appliances; and in spite of the increased safety and
certainty, the outcome of increased knowledge, with which such operations
are now performed, the use of these has not been entirely superseded,
and in America they are still much in vogue. These appliances are called
obturators or artificial vela according to their position and function in
the mouth.

“An _obturator_ is a stopper, plug, or cover, stationary, and fitting
to an opening, with a well-defined border or outline, and closing the
passage.

“An _artificial velum_ is an elastic moveable valve, under the control
of surrounding or adjacent muscles, closing or opening the posterior
nares at will, and applicable to cases of congenital cleft, occasionally
when the soft palate has been destroyed by ulceration, but never merely
to perforations of the hard, or soft palate.”[98] Such are the Utopian
definitions given by American dentists.

It may be interesting to pass in review some of the ingenious appliances
which have been from time to time suggested, and to indicate some of the
various steps in the progress of their production.

It is evident that the ancient Greeks were acquainted with some means
of closing or remedying acquired or congenital defects of the palate;
but nothing is known definitely of the method adopted. In the year 1565
Petronius, in his work ‘De Margo Gallico,’ proposed to close the opening
by wax, cotton, or with a gold plate adapted to the curve of the palate;
but in all probability this was no new suggestion. Ambrose Paré, in his
book on Surgery, published in Paris in 1579, translated into English in
1649, suggests that the cavity should be covered over by a gold or silver
plate, “made like unto a dish in figure, and on the upper side which
shall be towards the brain, a little sponge must be fastened, which when
it is moistened with the moisture distilling from the brain will become
swollen and puffed, so that it will fill the concavity of the palate,
that the artificial palate cannot fall down, but stand fast and firm,
as if it stood of itself.” A modification of this was suggested shortly
after by Isaac Guillemeau, who, to increase the accurate adaptation of
the obturator, proposed a “packing” of sponge or lint around the edges
of the apparatus. At the beginning of the eighteenth century, Garangeot,
in his ‘Treatise on Instruments,’ proposed to fix the sponge, which was
placed above the obturator in the nose, by passing through it a screw
stem, arising from the upper surface of the plate, and screwing a nut
down upon it; evidently trouble had arisen in some cases from the nasal
sponge becoming liberated, and retained in the nose.

In this country, Wiseman, Sergeant-Surgeon to King Charles II, suggested
the accurate filling of the cleft with a paste composed of myrrh,
sandarac, and a number of other ingredients; but as to the means by which
this was to be maintained in position we are left in ignorance.

The discontinuance of the nasal sponge seems to have first occurred to
Astruc, who, in his ‘Treatise on Syphilis’ (1754), replaces it by a
silver button attached to the upper surface of the obturator in order to
avoid the unpleasantness arising from the absorption of mucus. This was
soon followed by another suggestion emanating from M. Pierre Fouchard
(1786), who describes a silver obturator with an arrangement of metallic
wings, worked into position after introduction through the opening by
means of a hollow stem and nut, which, when screwed down, kept the
wings covered with soft sponge across the aperture. The introduction
of “elastic gum” as a suitable substance to be used in the restoration
of the velum and uvula was the next step in advance; this was utilised
in 1820 by M. De la Barre, who devised some very clever, but extremely
complicated pieces of mechanism. Thus far it appears that no particular
precautions had been taken to secure the accurate fitting of the
apparatus; but in 1828 Snell drew attention to the necessity of obtaining
an accurate model of the mouth, and his results, in consequence, were
much more satisfactory. Since that period various instruments have
been devised and used with more or less success; but in this work it
is unnecessary to do more than mention the names of Stearns, Kingsley,
Sercombe, Ramsay, Oakley Coles, and Wolff as being authorities on the
subject, and to indicate some of the plans adopted.

The obturators employed in recent days have been much simplified, and
practically have been reduced to a simple plate fixed in the roof of the
mouth by an arrangement similar to that employed for ordinary dental
plates, _i. e._ attached to one or more of the teeth. This is a great
improvement on the old form of “plug” obturator, which by its constant
pressure had the effect of increasing the size of the opening.

Artificial vela are always somewhat complicated, and that success will
attend their use cannot be assured. They consist of a vulcanite or gold
palate plate fastened to some of the teeth, and of a moveable flap
attached to it by a hinge and spring of suitable strength (Figs. 72 and
73), or simply of a rubber flap sewn to the posterior margin of the plate
(Fig. 74). These vela either rest above the palatal segments, or their
sides can be grooved to allow the palatal segments to fit into them. It
is very difficult to obtain an artificial velum sufficiently strong to
retain its position, and yet light enough to allow of its being easily
moved by the displaced and probably weakened muscles.

[Illustration: FIGS. 72 AND 73.—Figures of artificial velum as seen from
below and above, consisting of a metal palate plate with a velum hinged
to it, and supported above by a spring of suitable strength. (_Coles._)]

[Illustration: FIG. 74.—Another form of artificial velum. (_Coles._)]

In 1864 Dr. N. W. Kingsley, of America, suggested for this purpose the
use of soft india rubber of such delicacy as to resemble the normal
velum as nearly as possible. The rubber was arranged in two layers, one
of which rested above and behind the cleft, and the other overlapped for
about half an inch all the margins of the cleft seen from the front. This
amount of overlapping was found sufficient to prevent the apparatus from
becoming displaced during muscular contraction, and at the same time by
its means allowed the palate muscles to effect closure of the posterior
nares.

Mr. Baker, in the ‘Boston Medical and Surgical Journal,’[99] describes
a velum consisting of rubber distended with water, which was fixed with
a hinge to the back of the palatal plate, and under the control of the
muscles by being inserted above them on either side. A stop prevents it
falling too low, and the posterior extremity is almost semicircular to
allow of perfect apposition with the pharyngeal wall, which is drawn
forward by the superior constrictor. He claims to have met with much
success.

Wolff and Schiltsky have devised a similar apparatus, but use air instead
of water for distending the hollow rubber velum.

       *       *       *       *       *

The main arguments that have been educed in favour of the use of
artificial substitutes for the palate rest upon the fact that until
recently the results of operative interference in severe cases of
fissured palate were often very unsatisfactory; in most, if not all, an
aperture was left anteriorly, which caused the speech of the patient
to remain indistinct. But with the greater success which has followed
increased experience and practice, this cause can be eliminated; and,
moreover, secondary operations for the attainment of this object can
always be undertaken with every prospect of success. Another objection
raised to operation is that no immediate improvement takes place in the
power of clear articulation; and although this is perfectly true, the
patient is in the same condition in this respect as when first provided
with an obturator, and will require the same educational process for the
improvement of speech. Again, the mental effect on patients operated
on is much more satisfactory than that following the application of
artificial assistance; whilst the presence of a foreign body in the mouth
is a source of continual danger and irritation; for there is always
the possibility of the obturator slipping out of position and becoming
impacted in the pharynx or œsophagus. Irritation of the sides of the
cleft not uncommonly results from their use, and may end in ulceration
and even necrosis. When obturators and vela are removed from the mouth,
a spongy granulating surface is often seen, bleeding on the slightest
touch, and giving rise to a peculiar fœtor of the breath. Under these
circumstances a temporary discontinuance of the apparatus becomes
necessary, a most undesirable and unpleasant contingency.

Again these appliances cannot be fitted to a patient much before the age
of fifteen, and the habit of defective articulation has been fully formed
by that time. They also need constant renewal, and are thus a source of
continual expense, putting them beyond the reach of hospital patients.

In spite, therefore, of the optimistic arguments so boldly maintained
by our American dental confrères, and of the successes they claim
to have attained by the use of these artificial means, I am driven
to the conclusion that in the majority of cases of cleft palate
operative interference, followed by a suitable educational course, will
give results incomparably superior to these, and unattended by the
above-mentioned disadvantages.

But whilst strongly maintaining the superiority of the treatment by
operative rather than by mechanical means, I will readily grant the
greater applicability of the latter in certain conditions; viz. in
acquired defects of the palate, the results of syphilis, traumatism,
or surgical operations involving extensive loss of tissue—as, for
instance, after excision of the superior maxilla: obturators are almost
invariably the only means by which these apertures can be closed. In
cases of congenital cleft where the os incisivum has needed removal,
leaving a broad anterior opening the closure of which by operation is
often impossible (p. 135), the application of an obturator is similarly
advisable; and one suggests this method of treatment the more readily
from the ease with which it can be effected, inasmuch as it merely
necessitates an extension backwards of the plate which carries the
artificial incisors. The communication between nose and mouth is thus
effectually closed, and the functional success of previous plastic work
and subsequent educational efforts ensured.

In cases of hopeless deformity, where the palatal tissue is so attenuated
that operative interference is impracticable, the recourse to artificial
assistance is inevitable; but such cases are fortunately rare.




CHAPTER VIII.

RESULTS OF TREATMENT—AFTER-TREATMENT.


The typical result which we desire to gain after an operation for harelip
is a symmetrical appearance of lip and nose, and a normal contour and
projection of the parts as seen from the front and in profile. The
cicatrix should be practically invisible, and the red margin of the
lip continuous throughout. Unfortunately, however, in many cases these
results are not easily attainable. The tip of the nose tends to become
drawn down and depressed, especially when in double harelip the philtrum
is poorly developed, or when a mistaken attempt is made to incorporate
it between the segments of the lip. This stunted but thickened columna
encroaches on and obstructs the anterior nares, whilst in unilateral
cases the aperture on the affected side is apt to become dilated and
distended from the absence in some instances of the osseous floor, but
also from subsequent cicatricial contraction of the previously divided
bands between the cheek and maxilla. The behaviour of young cicatricial
tissue, moreover, is not always the same. In some young and feeble
children it remains vascular for a long time, and at first tends to
stretch and become more evident;[100] subsequently contracting, it may
leave an indurated cord-like ridge. In addition to this, a longitudinal
contraction takes place in direct proportion to the thickness of the
cicatrix, reducing the length of the scar and the depth of the lip, thus
bringing about the 𝖵-shaped notch in the lip margin, and assisting in the
dilatation of the nostril.

In double harelip, where the os incisivum has been removed, it has
already been mentioned that the upper lip sinks back, the lower lip
projects forwards, and the profile resulting therefrom becomes very
unsightly (Fig. 75).

[Illustration: FIG. 75.—Profile of a case of double harelip after
operation with removal of the os incisivum, showing the falling in of
the upper lip and the prominent projection of the lower. (_Coles._)]

Many of these defects may be remedied by subsequent treatment. I am
frequently in the habit of advising and practising secondary operations
for the improvement of the facial expression in young children and
adults presenting the unsatisfactory cicatrices detailed above. The
operation comprises not only the removal of scar tissue, but also the
obliteration of the 𝖵-shaped notch, elevation of the depressed nose,
and the diminution in size, if necessary, of the nasal aperture. For a
simple 𝖵-notch without other complications, I have sometimes made use of
Nélaton’s operation (Fig. 48) with most satisfactory results.

The narrowing or partial obliteration of the nostrils in double harelip
from the large size of the columna has sometimes to be remedied
subsequently. One plan which I have practised several times for reducing
the breadth of the columna is by excising a central lenticular-shaped
portion, extending nearly the whole length through its entire thickness,
and closing the gap with sutures. But a simpler method consists in paring
the edges of the columna on either side to the required dimensions,
and allowing the raw surfaces thus formed to cicatrise. The redundant
tissue should be removed on the inner or nasal aspect, so that when
cicatrisation takes place the skin is drawn round into the nares, and the
resulting scar is unobtrusive.

The falling in of the upper lip after the operation for double harelip,
when the os incisivum has been removed, can best be remedied by the
adjustment of a plate carrying the required artificial incisors, and
furnished with a central cheek-plate to restore the natural profile.
Where the lower lip projects unduly in spite of the above-mentioned
artificial adjustment, it may be requisite to reduce its size by the
removal of a 𝖵-shaped portion from its centre. This is so easily
accomplished as to need no detailed description; suffice it to say that
the greatest care is needed in the accurate application of the sutures.

I cannot conclude this portion of my subject without mentioning the
manual and mechanical aids which may be beneficially employed for the
improvement of the mobility and appearance of the face and nose after
such operations. The under-cutting of the integuments of the lip and
cheek, and the subsequent cicatrisation involved, necessarily lead to
a certain amount of rigidity of the parts. This can be remedied in a
great measure by persistent gentle manipulation of the lip and cheek,
care being taken always to press the parts towards the median line.
This should be carried out by the mother or nurse daily after due
instruction. A slight depression or collapse of the nostril on one
side can be improved by the use of an apparatus supplied by Messrs.
Hawksley, consisting of a head-band across the forehead, to which are
attached vertical stems ending in smooth bulbs, which, by rack and pinion
movement, can be so adjusted as to press the nostril into the desired
position. The apparatus can be worn at night and for a certain time
during the day.

       *       *       *       *       *

The conditions which are essential to a complete success after plastic
operations for cleft palate are as follows: complete closure of the cleft
with no fistulous communication in any part of the line of union, and a
velum capable, when necessary, of being approximated to the posterior
pharyngeal wall so as to shut off the nasal cavity during speech and
deglutition. That this is not invariably attained is an undoubted fact,
and in spite of the merest shaving being removed when paring the edges of
the cleft, the velum when united is frequently so scanty as to be unable
to fulfil this condition. To remedy this, it was proposed some years ago
by the late Mr. Mason to loosen the soft palate by lateral incisions,
passing downwards and backwards through the free border, thus relaxing
the tension, and allowing it to be drawn upwards, when requisite, into
relation with the pharyngeal wall. I have adopted this plan in several
cases, but with only transient success, inasmuch as the subsequent
cicatrisation of the incisions neutralises the temporary benefit derived.
The division of the pillars of the fauces, however, is occasionally
needful and more satisfactory. This has been already alluded to (p.
127), and may either be performed at the time of the first operation, or
subsequently if found to be necessary.

Even in cases where the tissue is abundant, and the united velum
loose and moveable, the immediate effect on the speech is not always
satisfactory. The other advantages of the operation (_e. g._ exclusion
of nasal mucus from the mouth, prevention of regurgitation of fluids
through the nose, improvement in taste and smell, and the psychical
effects) are immediately apparent; but speech is a more complicated
proceeding, and the first result of the operation is often to dislocate
the mechanism which the patient had formerly made use of in its
production, and hence, as has been often noticed, speech and voice may
be temporarily deteriorated, even after a successful operation. This is
a disappointment both to the patient and friends unless they have been
previously warned. A subsequent thorough educational course at the hands
of a professional voice-trainer, if possible, is therefore most important.

In some instances tension of the velum is no doubt the cause of the
persistent nasal twang, but in many others habit is the principal
factor, and this can alone be got rid of by a suitable education. The
reluctance to breathe through the mouth, and the unwillingness to open it
sufficiently during articulation, are conditions very liable to persist
after operation. Such patients also speak too rapidly and run the words
into one another, the velum evidently not being under control. The most
difficult letters to pronounce are _t_, _b_, _d_, _k_, _g_, _s_, _z_, and
_l_. The best means of dealing with the defective breathing is to make
the patient undergo a course of “respiratory gymnastics.” Thus he should
be made to practise deep abdominal breathing with the mouth wide open; he
should stand in front of a looking-glass, and breathe with his mouth open
and his tongue voluntarily depressed. He should next repeatedly exercise
the movements of his tongue and lower jaw; this is often productive of
great improvement in the facial expression. These exercises should be
followed up by others directed to the improvement of speech. The distinct
production of the various vowels and consonants and of all the sound
combinations must be a matter of daily practice. He should be made to
speak and read aloud according to the recognised laws of elocution,
and by so doing obtain proper modulation of the voice and fluency of
speech. Compression of the nasal apertures during these exercises is also
advantageous.

The physical condition of the hard palate after the operation of
uranoplasty is a subject of considerable interest. Langenbeck[101]
claimed that a new formation of bone really occurred about three or four
weeks after the operation, and attained in time considerable solidity.
From experiments, however, by M. Marmy on the palates of dogs, doubt
was thrown on the correctness of this assertion; and M. Ollier, so well
known as an authority on subperiosteal work, declares that “if there may
be doubt as to the ossification, all must admit that it forms a very
resisting surface, which has the strength and takes the place of bone.”
Opportunities for post-mortem investigation do not seem to have been
taken advantage of for deciding this question; but clinical experience
seems to indicate that no new bone is actually formed, the central
portion of the palate consisting merely of dense fibro-cicatricial tissue
covered with mucous membrane. In operating after a lapse of several years
for the closure of oval apertures in the hard palate in patients in whom
a previous operation had been but partially successful, I have never
found osseous tissue, either when paring the margins or when detaching
the flaps through lateral incisions.

The shape and size of the alveolar arch are sometimes considerably
affected as an after result of uranoplasty. It would appear that in the
young the contraction of the cicatrix between the palatal segments and of
the new tissue in the lateral openings exercises a narrowing influence
on the transverse diameter. The alveolar borders approach one another,
and this approximation is most marked at the level of the first or second
bicuspids, and indeed is so great occasionally as to produce an obvious
incurvation of the alveolar ridge. M. Ehrmann of Paris, has investigated
many instances of this change, and from his work[102] the figures
mentioned below are obtained.

In one case a child was operated on for total cleft at three and a half
years. Six months later the following measurements were taken:

    Transverse interval between canines        13 mms.
        ”              ”        1st molars     18  ”
        ”              ”        2nd  ”         26  ”


At twenty-three years of age the following were the measurements:

    Transverse interval between canines         7 mms.
        ”              ”        1st premolars  13  ”
        ”              ”        2nd    ”       19  ”
        ”              ”        1st molars     23  ”
        ”              ”        2nd   ”        32  ”

The alveoli here formed a reversed 𝖵, and when the patient spoke, the
tongue was more or less protruded. In another case, operated on at five
years of age for the palate defect, a double harelip having been treated
at an earlier date, the measurements were—

                                   At 5 years.  At 6 years.  At 11 years.
    Intervals between canines        23 mms.      19 mms.      12 mms.
           ”          1st premolars  27  ”        24  ”        14  ”
           ”          2nd    ”       32  ”        27  ”        19  ”
           ”          1st molars     —            —            23  ”


This result is more frequently seen in the severer forms of cleft palate
associated with double harelip, especially where the os incisivum has
been removed. Extreme youth increases the tendency to the production of
these deformities, which may become troublesome, not only by interfering
with the size of the buccal cavity, and so causing protrusion of
the tongue during speech, but also by interfering with the “bite,”
necessitating lateral movement of the jaw during mastication.

In one of Ehrmann’s cases an actual increase of the interdental diameters
was found; this was one in which Fergusson’s osteoplasty had been
performed with complete success; possibly the formation of new bone from
the callus produced led to this, or it may have been merely an evidence
of normal growth. The measurements were as follows:

                                   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.




ADDENDUM.

RECTAL ANÆSTHESIA.


The plan of inducing anæsthesia _per rectum_, which has recently been
brought before the profession in this country by Dr. Dudley Buxton, was
originally suggested by Pirogoff in 1847, ether being the agent employed;
but the introduction of chloroform in 1848 led to the disuse of ether
in any way for many years. More recently Pirogoff’s suggestion has been
resuscitated, and made use of by Bull, Weir, and others in America,
Ollivier and Molière in France, by Iversen and Wancher in Copenhagen, and
by Dudley Buxton in this country. The last-named anæsthetist recommends
an apparatus (supplied by Mayer and Meltzer) consisting of a receiver
for the ether, which is placed in water at about 120° F. The vapour
thus given off is conducted by a ¾-inch rubber tube, about four feet
long, through a specially constructed intercepter to prevent any liquid
ether bubbling into the rectum, and enters it by an anal tube. A special
device maintains sufficient pressure upon the perineal pad to prevent
the escape of flatus or ether from the bowel. Anæsthesia may be induced
from the first in this manner; or, as a preliminary step, chloroform
or ether may be given by inhalation in the usual way, and the rectal
administration subsequently relied on. The disadvantage of this combined
method is the difficulty of judging when the absorption by the rectum is
sufficient to be trusted alone; otherwise the patient may regain partial
consciousness, and struggle. When the rectal plan only is used, the
patient is often twenty or thirty minutes becoming unconscious, although
ether may be smelt in the breath within five of its commencement. There
is no excitement or struggling, and fewer after-effects. Care must be
taken to regulate the amount of ether used, or abdominal distension and
rectal catarrh may result; particularly is this the case if the operation
be protracted. The method may prove of value, when properly employed, in
operations involving the tongue, lips, pharynx, larynx, palate, jaws,
&c. There are, however, obvious dangers in connection with its use, and
unfortunately these fears have been realised in America by the combustion
of the vapour leading to rupture of the bowel and other disastrous
consequences.




FOOTNOTES


[1] Trendelenburg, ‘Deutsche Chirurg.,’ Lief. xxxiii, Hälfte 1.

[2] Rouge, ‘L’Uranoplastie et les divisions congénitales du palais.’

[3] Oakley Coles, ‘Deformities of the Mouth’ (Churchill).

[4] Dieffenbach, ‘Die operative Chirurgie’ (1845).

[5] Mason, ‘On Harelip and Cleft Palate’ (Churchill), p. 54.

[6] Op. cit., p. 55.

[7] Warner, ‘Brit. Med. Journ.,’ 1889, July 27th.

[8] ‘Trans. Path. Soc.,’ xxxviii, p. 446.

[9] ‘Bull. de Soc. Anat. de Paris,’ December, 1883.

[10] Ibid., April, 1886.

[11] See p. 52.

[12] ‘Medical Times,’ 1862, p. 402.

[13] Trendelenburg, ‘Deutsche Chirurg.’ (Billroth and Luecke), Lief,
xxxiii, Hälfte 1.

[14] ‘Trans. Odont. Soc.,’ vol. xx, p. 90.

[15] Similar cases have been recorded by Von Ammon, Hippe, Liebrecht,
Beely.

[16] ‘Archiv f. klin. Chir.,’ xvi, p. 684.

[17] Ditto, xx, p. 396.

[18] Pelvet, “Mémoires sur les fissures congénitales des joues,” ‘Gaz.
méd. de Paris,’ 3 s., xix, p. 417.

[19] “Über die morph. Bedeut. der Kiefer, Lippen, und Gesichtsspalten,”
Langenbeck’s ‘Archiv,’ xxxi, 2.

[20] ‘Dublin Quart. Journ. of Med. Sci.,’ 1862, xxxii, 15.

[21] ‘Odontological Trans.,’ 1887, p. 105.

[22] ‘Bull. de Soc. Anat. de Paris,’ 1886, p. 599.

[23] ‘Bull. de Soc. de Chir.,’ 1860, ii, p. 642.

[24] ‘Bull. Gén. de Thérapeutique,’ 1862, lxii, pp. 13, 66.

[25] Op. cit.

[26] ‘Wien. klin. Wochen.,’ 1889, ii, p. 520.

[27] ‘Dict. de Sci. Méd. de Paris,’ viii, p. 642.

[28] Wölfler, ‘Langenbeck’s Archiv,’ 1890, xl, p. 795.

[29] ‘Gaz. des Hôpit.,’ 1870, liv.

[30] Parisé, ‘Bull. Gén. de Thérapeut. de Paris,’ 1862, lxiii, p. 269.

[31] Demarquay, ‘Bull. de Soc. de Chir.,’ Paris, 1869, 25, ix, p. 111.

[32] ‘Brit. Med. Journ.,’ 1863, i, p. 412.

[33] Manley, ‘New York Med. Journ.,’ June 15th, 1889.

[34] Kölliker, “Über das Os intermax., &c.,” ‘Nova Acta der Leopold
Akad.,’ Halle, 1882, p. 343.

[35] ‘Deutsche Zeitsch. für Chirurg.,’ 1885, p. 205.

[36] ‘Congrès Franc. de Chir.,’ 1888, p. 480.

[37] Op. cit., p. 5.

[38] ‘Insanity,’ p. 442.

[39] ‘Brit. Med. Journ.,’ 1889, ii, 1272; 1890, ii, 447.

[40] ‘Trans. Odontological Soc.,’ 1872, vol. iv.

[41] ‘On Oral Deformities.’

[42] For this chapter I am indebted to the pen of my colleague, Mr.
Carless.

[43] Sudduth, in ‘American System of Dentistry,’ vol. i, p. 648.

[44] Galen, ‘De Usu Partium,’ lib. ix, cap. 20; and ‘De Ossium Naturâ,’
cap. 3, p. 14.

[45] Nesbitt, ‘Human Osteogeny,’ London, 1736, pp. 90, 91.

[46] Goethe, ‘Sammtliche Werke,’ in 36 vols., Cotta, 1868; vol. xxxii, p.
159.

[47] Vicq d’Azyr, ‘Œuvres,’ iv, p. 159.

[48] ‘Philosophical Trans.,’ 1869, p. 166.

[49] Gilis, ‘Bull. de Soc. Anat. de Paris,’ 1888, p. 372.

[50] The dotted line from _e_ is erroneously prolonged a little beyond
the suture.

[51] ‘Virchow’s Archiv,’ Bd. cxi, i, p. 125; ‘Anat. Anzeiger’ (Breslau),
1888, p. 577.

[52] Albrecht: (1) “Die Morph. Bedeutung der seitliche Kieferspalte,”
‘Zool. Anzeig.,’ 1879, p. 207. (2) ‘Sur les 4 Intermaxillaires, &c.,’
Soc. d’Anthropol. de Brux., 1883. (3) “Über die morph. Bedeutung der
Kiefer-, Lippen-, und Gesichts-spalten,” ‘Lang. Archiv,’ xxxi, 2; ‘Centr.
für Chirurg.,’ 1884, 4. (4) “Zur Zwischenkieferfrage,” ‘Fortschritt
d. Med.,’ 1885, iii, 14. (5) “Über sechs-schneidezähnige Gebisse beim
normalen Menschen,” ‘Centr. für Chir.,’ 1885, No. 24. (6) “Über den
morph. Sitz der Hasenscharten Kieferspalten,” ‘Biolog, Central.,’ 1886,
vi, 3, pp. 80 and 122.

[53] Sabourand, ‘Bull. de Soc. Anat. de Paris,’ 1890, No. 13, p. 270.

[54] ‘Bull. de Soc. Anat. de Paris,’ 1886, p. 350.

[55] ‘Journ. of Anat. and Phys.,’ xix, p. 198.

[56] “Über das Os intermax. des Menschen und die Anat. des Hasenscharte
und des Wolfsrachen,” ‘Nova Acta der Leopold Carol. Akad. der
Naturforscher,’ Halle, 1882, Bd. xliii, No. 5, p. 369.

[57] “Über den morphol. Sitz der Hasenscharten Kieferspalten,” ‘Biolog.
Central.,’ Bd. v, 13, pp. 80 and 122.

[58] “Lippen und deren Complicationen,” ‘Virchow’s Archiv,’ cxi, p. 138.

[59] Occasionally the lateral or accessory incisor may be developed or
suppressed on one side only, a fact explaining the occasional occurrence
of cases with three or five incisors present.

[60] Kölliker, op. cit., p. 369.

[61] Biondi, op. cit.

[62] ‘Langenbeck’s Archiv,’ xl, p. 795.

[63] ‘Trans. Med.-Chir. Soc.,’ 1845.

[64] Churchill, 3rd edition, 1881, chap. vi.

[65] Op. cit., p. 109.

[66] ‘Archiv f. klin. Chirurg.,’ v, p. 52.

[67] Trendelenburg, ‘Deutsche Chirurg.,’ Lief. xxxiii, Hälfte 1.

[68] ‘Deut. Zeitsch. für Chir.,’ xix, p. 15.

[69] Hermann, ‘Beitr. z. Statistik und Behandlung der Hasenscharten,’
Diss. Breslau, 1884.

[70] Gotthelf (Heidelberg), ‘Archiv f. klin. Chir.,’ xxxii.

[71] Op. cit., p. 39.

[72] Trendelenburg objects to the harelip operation being called a
life-saving one, on the ground that the inability to gain sufficient
nutriment depends rather on the associated cleft palate than on the cleft
lip. But if the lip be united efficiently the method of feeding by bottle
suggested at p. 66 enables the child to suck and swallow satisfactorily
in spite of the palatal defect.

[73] Fergusson, ‘A System of Practical Surgery’ (Churchill), 1865, p. 497.

[74] ‘The Works of the famous Chirurgeon, Ambrose Paré’ (1579),
translated in 1678 by Th. Johnson.

[75] In view of the dilatation of the nasal aperture, which often takes
place at a later date, it is advisable to make it at first actually
smaller than on the opposite side.

[76] The lower lip may also be kept drawn down and everted by the use of
collodion applied longitudinally between it and the chin, thus obviating
in part the need of the constant application of the nurse’s finger. This
ingenious plan has been suggested and practised by one of the sisters in
my wards at King’s College Hospital.

[77] ‘Dict. de Médicine,’ p. 703; M. Coste, ‘Lancet,’ 1851, ii, 203.

[78] ‘Dublin Quart. Journal,’ 1868, vol. xlv, p. 269.

[79] It may be interesting to quote Franco’s own words on this
subject:—“Pour l’extirpation de telle turpitude, nous y deuous en premier
lieu procéder de la manière que dessus (_Cure des leures fendues_, ch.
119), hormis que quand les dents et mandibules passent dehors, et que ne
peuuent estre couuertes de la bouche, il n’y a point de danger de copper
le superflu et ce qui ne sert à rien avec tenuailles incisiues ou auec
scie ou autre instrument propre à cest essait, en laissant la chair qui
est dessus icelles dents s’il y en a, affin qu’elle serue en cousant les
deux autres parties en icelles de chaque costé, et s’il y auoit telle
distance entre lesdites leures qu’on ne peut les assembler, il faudrait
user de semblables dissections en la bouche qu’au cas précédent, et
procéder au reste ainsi qu’auons montré” (Franco, _Traité des hernies,
&c., cure de dents de lieure_, chap. cxxii, Lyon, 1561).

[80] Sédillot, ‘Gaz. des Hôp.,’ 1861, Nov. 7th.

[81] ‘Journal de Malgaigne,’ Jan., 1843.

[82] Bardeleben, ‘Lehrbuch der Chirurgerie und Operationslehre,’ 1872,
vol. ii, p. 252.

[83] Butcher, ‘Essays on Operative Surgery,’ p. 715; ‘Dublin Quarterly
Journal of Medical Science,’ xxix, p. 296.

[84] ‘Archiv,’ vol. ii, p. 230.

[85] The central portion requires catgut stitches in addition to being
transfixed by the upper wire.

[86] Ehrmann, “Des operations plastiques sur la palais chez l’infant,”
Cong. Franc. de Chir. 1888, p. 462.

[87] Many of the points alluded to under this heading are obtained from
an excellent paper furnished me by Mr. G. L. Cheatle, late Surgical
Registrar to King’s College Hospital, who has had considerable experience
in such work.

[88] ‘Lancet,’ vol. ii, 1852.

[89] Graefe, ‘Hufeland’s Journal,’ 1816.

[90] Roux, ‘Mémoire sur la Stapyloraphie,’ Paris, 1825.

[91] ‘Mémoires sur différents objets de Médicine,’ Paris, 1764.

[92] ‘Dictionnaire de Médicine et de Chirurgie Pratiques,’ 1836, vol. xv,
p. 19.

[93] ‘Die Operative Chirurgie,’ von Johann Friedrich Dieffenbach, Erster
Band, 1845, p. 856.

[94] Trélat, “Technique des operations plastiques sur le Palais,” Revue
de Chirurg., 1886, p. 89.

[95] ‘Brit. Med. Journ.,’ 1890, ii, 950.

[96] Rotter, ‘Munch. Med. Wochensch.’ 1889, xxxvi, p. 535.

[97] Wolff, ‘Berl. Klin. Wochensch.,’ 1889, p. 577.

[98] ‘Amer. Syst. of Dentistry,’ vol. ii, p. 1056.

[99] Baker, ‘Boston Med. and Surg. Journ.,’ 1889, p. 212.

[100] This is more likely to happen if the stitches are removed too soon
from loss of their support.

[101] ‘Archiv für klin. Chir.,’ vol. v, 1, p. 3.

[102] Ehrmann, “Des opérations plastiques sur le palais chez l’enfant;
leurs résultats éloignés,” ‘Cong. franç. de Chir.,’ 1888, p. 462.




INDEX.


  A.

  Accessory teeth in harelip, 54

  Acquired apertures in palate, treatment of, 144

  Adenoids in cleft palate, 71
    question of removal of, 70, 104

  Adults, harelip in, 69

  After-treatment of harelip operations—
    immediate, 85
    mechanical and manual aids, 148
    secondary operations for broad columna nasi, 148
      V-notch, 147

  After-treatment of palate operations—
    educational, 150
    for tension of velum, 149
    immediate, 127

  Age for harelip operations, 74
    palate operations, 101

  ALBRECHT, chief works of, 49
    on accessory teeth in os incisivum, 54
    on intermaxillary sutures, 27
    on morphological position of alveolar harelip, 45, 48

  Alveolar harelip, 3
    dentition of, 51, 54
    morphological position of, 48

  Anæsthesia in cleft palate operations, 105
    in harelip operations, 77
    per rectum, 157

  Animals, occurrence of deformities of, 10

  Articulation, action of palate in, 35
    defective after successful operation, 150
    education required to improve, 150
    in cleft palate, 69

  Artificial vela, arguments for, 143
    definition of, 139
    objections to, 144
    varieties of, 142

  Assistant, duties of, in palate operations, 107

  Atresia of nose, congenital, 14

  Auricular appendages in macrostoma, 20

  Author’s gag for operations on mouth, 109
    incisions for double harelip operation, 98
      single harelip operation, 81


  B.

  BARDELEBEN’S treatment of os incisivum, 94

  BIONDI on intermaxilla, 47

  BLANDIN’S treatment of os incisivum, 94

  Bony suture of palate, or osteoplasty, 133

  Breadth of cleft palate diminished after closure of lip, 73
    palate decreased after closure of cleft, 151

  Breath, fœtid, in cleft palate, 71

  Buccal cleft, or macrostoma, 19

  BUTCHER’S treatment of os incisivum, 95


  C.

  CALLENDER on intermaxilla, 46

  CARLESS on intermaxillary sutures, 26
    on intra-uterine cicatrix of lip, 5
    on maternal shock, 25

  Causes of congenital deformities, 23

  Caustics in acquired deformities, 156
    use of, after palatal operations, 132

  Cheiloplastic operations for harelip, 91, 99

  Classification of deformities of mouth, 1

  Cleft palate, absence of uvula in, 9
    action of muscles in, 64
    arrangement of muscles in, 63
    articulation in, 69
    associated deformities, 11, 65
    closed by facial flaps, 137
    condition of pharynx in, 71
    cranial deformities associated with, 65
    development of, 59
    effect of varying slope of segments, 65
    feeding of patients with, 67
    fœtid breath in, 71
    frequency of, 9
    functional results of, 67
    influenced by closure of harelip, 73
    moral effect of, 69
    occurrence in animals, 10
    operative treatment of (_see_ Operative treatment of cleft palate)
    pharyngeal complications, 71
    slope of segments in, 9, 65
    taste in, 71
    uncommon varieties of, 8
    varieties of, 5
    vomer in, 6
    width of, 9

  COLES, nipple-shield for feeding infants with cleft palate, 68
    on cranial deformities in cleft palate, 65
    on size of normal palate, 32

  COLLIS’S operation for unilateral harelip, 90

  Collodion dressing for harelip, 84

  Columna nasi, condition of, after bilateral operation, 146
    secondary treatment of, 148

  Condition of palate, immediate, after operation, 126
    remote, after operation, 151

  Cranial deformities in cleft palate, 65


  D.

  DAVIES-COLLEY, method of closing cleft palate, 134

  Deformities associated with harelip and cleft palate, 11
    of cranium in cleft palate, 65
    of palate associated with mental dulness, 33

  Deglutition, normal action of velum in, 34

  Dentition in alveolar harelip, 51, 54
    in facial clefts, 58

  DESAULT on treatment of os incisivum, 93

  Development of anterior nares, 41
    of bones of skull, 42
    of eyes, 38
    of face, 37, 41
    of intermaxilla, 43, 44
    of mandible, 37
    of mouth, 36
    of nasal duct, 41
    of nose, 39
    of palate, 40, 43
    of teeth, 43
    of tongue, 41

  DIEFFENBACH’S operation for unilateral harelip, 91

  Division of levator palati by Fergusson’s method, 125
    Pollock’s method, 126

  Dog-nose, 15

  Double harelip, median tubercle in, 61
    operative treatment for (_see_ Operative treatment for double
        harelip)
    os incisivum in, 3, 62

  Dressing for harelip operations, 84


  E.

  Edges, how to pare, in cleft palate, 120

  Education of patients after palatal operations, 150

  EHRMANN on change of shape of palate after uranoplasty, 151
    on normal shape and size of palate, 32
    statistics of early operations for cleft palate, 101

  Endognathion, 27, 45

  Exognathion, 27, 45

  External nasal process, 39
    its relation to the lip, 56, 57

  Extirpation of os incisivum, 92
    _v._ reposition, 96


  F.

  Facial cleft, 16
    associated with harelip, 18
    morphological position of, 57
    varieties of, 17

  Feeding of infants after harelip operations, 76, 85
    with cleft palate before operation, 67
      after operation, 128

  FERGUSSON (Sir W.), loop-method of passing sutures, 121
    method of dividing muscles in staphyloraphy, 125
    on muscles in cleft palate, 63
    on os incisivum, 62
    osteoplasty, 133

  Fissure of cheek (_see_ Macrostoma), 19
    lower lip (_see_ Mandibular cleft), 21
    palate (_see_ Cleft palate), 5
    upper lip, facial cleft, 16
      harelip, 2, &c.
      median harelip, 12

  Fœtid breath in cleft palate, 71

  Food, regurgitation of, in cleft palate, 67

  Forceps for palate operations, 111

  FRANCO on removal of os incisivum, 92


  G.

  Gag, author’s, in operations on the mouth, 109
    Mason’s, 109
    T. Smith’s, 108

  GENSOUL, forcible repression of os incisivum, 93

  GILIS on intermaxilla in fœtus, 46

  GIRALDÉS’ or mortise operation for harelip, 88

  Globular processes, 39
    absence of, in median harelip, 58

  GOETHE on intermaxilla, 45
    on morphological position of alveolar harelip, 45, 48

  GRAEFE, operation for unilateral harelip, 86


  H.

  Hæmorrhage in palate operations, 117, 126
    secondary, 132

  HAINSBY’S truss, 84

  Hard palate, abnormal shape of, 33
    function of, 34
    history of operations upon, 115
    measurements of, 32
    mucous membrane of, 30
    operative treatment of (_see_ Operative treatment of cleft palate)
    osteology of, 26
    shape of, 32
      after uranoplasty, 151
    syphilitic disease of, 154
    vascular supply to, 30

  Harelip, action of labial muscles on, 60
    ætiology of, 23
    alveolar (_q. v._), 3
    anatomy of, 60
    associated deformities, 11
    causes of nasal deformity, 61
    characters of, 2
    condition of parents’ mouths in, 23
    connections with maxillæ, 61
    frequency of, 9
    hereditary character of, 23
    intra-uterine closure of, 5
    maternal impression or shock in, 24
    median (_see_ Median harelip), 12
    nose, shape of, in, 3
    occurrence of, in animals, 10
    operation for double, author’s, 98
      Bardeleben’s, 94
      Blandin’s, 94
      Butcher’s, 95
      Desault’s, 93
      Franco’s, 92
      Gensoul’s, 93
      Langenbeck’s, 95
      Sédillot’s, 99
      T. Smith’s, 100
    operation for single, author’s, 81
      Collis’s, 90
      Dieffenbach’s, 91
      Giraldés’, 88
      Graefe’s, 86
      König’s, 89
      Malgaigne’s, 87
      Mirault’s, 89
      Nélaton’s, 86
      Stokes’s, 89
    operative treatment for (_see_ Operative, &c.)
      double, 92
      single, 77
    percentage of, in different sexes, 4

  Hare’s lip, characters of, 2

  Heredity in harelip, 23

  Hexaprodontous jaws, 27, 53


  I.

  Incisions in uranoplasty, 117
    hæmorrhage from, 117, 126
    lateral, in staphyloraphy, 126
    secondary hæmorrhage from, 132

  Instruments for palate operations, 108

  Intermaxilla, absence of, in median harelip, 12
    Albrecht on, 45
    Biondi on development of, 47
    Callender on, 46
    development of, 39, 43, 44, 56
    Gilis on development of, 46
    Goethe on, 45

  Intermaxillary sutures, number of, 27, 46
    relations of, to alveolar harelip, 47
      to facial cleft, 57
      to median harelip, 58

  Intra-uterine closure of harelip, 5


  J.

  Jaw, treatment of aperture after removal of upper, 145


  K.

  KÖLLIKER on dentition in alveolar harelip, 52

  KÖNIG, operation for unilateral harelip, 89


  L.

  LANGENBECK on condition of palate after operation, 151
    operation of uranoplasty, 115
    treatment of os incisivum, 95

  Levator palati, description of, 28
    division of, by Fergusson’s method, 125
      by Pollock’s method, 126
    function of, 29

  Lip, compressors of, in harelip operations, 80
    development of lower, 37, 58
      of upper, 39, 56
    underhung condition of lower, 147
    use of collodion in depressing lower, 85


  M.

  Macrostoma, 19
    auricular appendages in, 20
    morphological cause of, 58
    results of, 21

  MALGAIGNE, operation for unilateral harelip, 87

  Mandibular cleft, 21
    morphological cause of, 58

  MASON’S gag, 109
    method for relieving tension of united velum, 149
    modification in osteoplasty, 133
    teat for infants with cleft palate, 67

  Maternal impression or shock, 24

  Mechanical and manual after-treatment of harelip operations, 148

  Median harelip, 12
    cerebral malformations in, 14
    cranial defects in, 14
    morphological cause of, 58
    with intermaxilla absent, 12
    with intermaxillary cleft, 14

  Mental development in relation to shape of palate, 33

  Mesognathion, 45
    in alveolar harelip, 49

  MIRAULT, operation for unilateral harelip, 89

  Mouth, development of, 36

  Muscles of soft palate, 28
    division of, in staphyloraphy, 125, 126


  N.

  Nasal twang in cleft palate, 69
    causes of persistence of, after operation, 150

  Needles for palate operations, 112

  NÉLATON’S operation for unilateral harelip, 86
    use of, for recurrent V-notches, 147

  NESBITT on palatal sutures, 45

  Nipple-shield for infants with cleft palate, 68

  Nose, development of, 39
    shape of, in harelip, 3
    shape of, in harelip, cause of, 61
    shape of, in median harelip, 13, 14

  Nutrition, difficulty of, in cleft palate, 67


  O.

  Obturators, arguments in favour of, 143
    characters of recent, 141
    definition of, 139
    for acquired apertures, 144
    objections to, 144
    review of history of, 140
    use of, 144

  Operative treatment by facial flaps, 137
    of acquired apertures of palate, unsatisfactory character of, 156

  Operative treatment of cleft palate—
    after-complications, 129
    after-treatment, 127
    anæsthesia, 105
    anterior part of cleft, treatment of, 135
    assistant’s duties, 107
    condition of palate after, 151
    education of patient after, 150
    facial flaps employed for, 137
    hæmorrhage in, immediate, 117, 126
      secondary, 132
    history of, 115
    instruments for, 108
    osteoplasty, 133
    period for, 101
    position of patient in, 104
    preparation of patient, 103
    shape of palate after, 151
    staphyloraphy, 126
    superiority of, to mechanical appliances, 144
    sutures, materials employed for, 113
      methods of passing, 121, 123
      period for removal of, 129
    typical result, 149
    uranoplasty, 115

  Operative treatment of harelip—
    after-treatment, 85
    anæsthesia, 77
    detachment of lip from maxilla, 78
    dressing employed, 84
    effect of, on width of palatal cleft, 73
    feeding of infant after, 76, 85
    formation of prolabium, 79
    Hainsby’s truss, 84
    lip compressors in, 80
    period for, 72
    pins, use of, in, 81
    position of patient, 77
    preparation for, 76
    prevention of V-notch, 79
    stages of, 77
    statistics of, 74
    suturing lip, method of, 83
    typical result, 79, 146
    V-notch after, 147

  Operative treatment of double harelip (_see_ Harelip, operations for
        double)—
    of labial tissues, 98
    of os incisivum (_q. v._), 92
    usual result of, 147

  Operative treatment of single harelip (_see_ Harelip, operations for
        single)

  Os incisivum, dentition of, 54, 62
    description of, 61
    position of, in double harelip, 3

  Os incisivum, treatment of—
    extirpation (Franco), 92
    extirpation _v._ reposition, 95
    fixation of, after reposition, 95
    forcible repression (Gensoul), 93
    gradual repression (Desault), 93
    reposition after division of septum (Blandin, Bardeleben, Butcher),
        94

  Osteoplasty, Fergusson’s operation, 133
    Mason’s modification, 133
    reasons for discontinuance, 133


  P.

  Palate, acquired apertures in, 144, 154
    cleft (_see_ Cleft palate)
    development of, 40, 43
    hard (_see_ Hard palate)
    processes, 40
    soft (_see_ Soft palate)

  PASSAVANT on narrowing of cleft palate, 73

  Period for operation on cleft palate, 101
    on harelip, 72

  Philtrum, 62
    treatment of, 98

  Phonation in cleft palate, 35

  Pins, use of, in harelip, 81

  POLLOCK, method of dividing levator, 126
    on cleft palate, 64

  Position of patient in operation for cleft palate, 104
    for harelip, 77

  Preparation of patient in operations for cleft palate, 103
    for harelip, 76

  Prevention of V-notch, 79

  Prolabium, formation of, 79


  R.

  Raspatories for palate operations, 110

  Reposition of os incisivum (_see_ Os incisivum), 93

  ROSE (E.), position in palate operations, 104

  ROSE (W.), gag, 109
    operation for double harelip, 98
      single harelip, 81


  S.

  Secondary operation for closing fistulas in palate, 131
    prominence of lower lip, 97, 148
    reducing size of columna, 148
    tension of united velum, 149
    V-notches, 147
    possibility of, after sloughing, 138

  SÉDILLOT, operation for double harelip, 99

  Shape of hard palate, after uranoplasty, 151
    normal, 32

  SMITH (T.), direct method of suturing palate, 123
    gag, 108
    modification of uranoplasty, 134
    needle for palate operations, 124
    operation for double harelip, 100

  Soft palate, functions of, 34
    muscles of, 28
      methods of division of, 125, 126
    vascular supply of, 31

  Stages in operation for cleft palate, 116
    harelip, 77

  Staphylo-pharyngoraphy, 137

  Staphyloplasty, 137

  Staphyloraphy, 126

  Statistics of early operations for cleft palate, unfavorable, 101
    operations for harelip, 74

  STOKES’S operation for single harelip, 89

  SUTTON on median harelip, 13

  Sutures, direct method of passing, 123
    loop-method of passing, 121
    materials employed for, in lip operations, 83
      in palatal operations, 113
    method employed for adjusting, in double harelip, 99
      single harelip, 83
    period of removal of, after lip operations, 84
      after palate operations, 129

  Syphilitic affections of hard palate, 156
    velum, 155
    treatment of, 156


  T.

  Taste, improvement of, after closure of cleft palate, 150
    in cleft palate, 71

  Tertiary syphilitic affections of palate, 156

  Tonsils, enlargement of, in cleft palate, 70
    treatment of, 103

  Typical result after operation for cleft palate, 149
    harelip, 146


  U.

  Underhung lip after removal of os incisivum, 96, 147, 148

  Uranoplasty (_see_ Operative treatment for cleft palate)
    description of, 116
    effect of, on shape of palate, 151
    history of, 115

  Uvula, absence of, 9
    fissure of, 8
    method of suturing, 123
    muscles of, 29


  V.

  Velum palati (_see_ Soft palate)

  V-notches in lip margin after operation, 79
    treatment of, 147

  Voice, causes of non-improvement in, after operation, 150
    characters of, in cleft palate, 69
    education of, necessary, 150

  Vomer, condition of, in double harelip, 6, 63
    development of, 41, 43
    position of, in cleft palate, 6
    treatment of, in double harelip, 93
    use of mucous membrane over, 134


  W.

  WARNER on association of mental dulness, &c. with deformed palates, 33

  Wolf-jaw (Ger. _Wolfsrachen_), 3, 6

  WOLFF’S artificial velum, 143

  WÖLFLER on mandibular clefts, 58


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