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).