On harelip and cleft palate

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—

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.

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.

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.

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.

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.

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.

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.

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).