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Ebook has 617 lines and 53281 words, and 13 pages

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GENERAL INTRODUCTION.

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

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

DEVELOPMENT.

Normal development of mouth, face, nose, and teeth--Ossification--Development of intermaxilla; old ideas ; Albrecht's theory--Harelip; position of cleft in alveolus, and in lip--Dentition; accessory teeth--Development of other deformities 36-59

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

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

OPERATIVE TREATMENT OF CLEFT PALATE.

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

ON OBTURATORS AND ARTIFICIAL VELA 139-145

RESULTS OF TREATMENT--AFTER-TREATMENT 146-153

SYPHILITIC AFFECTIONS OF THE PALATE 154-156

ADDENDUM.

RECTAL ANAESTHESIA 157, 158

INDEX 159

ON HARELIP AND CLEFT PALATE.

GENERAL INTRODUCTION.

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:--

Median harelip .

Ordinary harelip .

Facial cleft .

Buccal cleft, or macrostoma .

Mandibular cleft, or median fissure of the lower lip.

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.

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 Par?, who probably initiated the treatment by pin and figure-of-8 suture. The name is really a misnomer, in that the condition 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 , 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.

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.

Harelip seems to occur more commonly in boys than in girls. According to M?ller, 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 M?ller 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; K?lliker 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.

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.

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 . 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 .

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 and Oakley Coles 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 ; 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 .

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 ; a defective development of the palate bones alone, the mucous membrane remaining intact from side to side, and hence no cleft resulting ; 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 . 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 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 .

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. Cred? 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.

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