On harelip and cleft palate

by William Rose

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]).

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.)

Fig. 10.

Fig. 10.—Complete cleft palate without alveolar or labial deformity; the vomer is separate from the lateral segments. (Mason.)

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]).

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]).

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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.