CHAPTER IX.. Syphilitic Affections of the Palate.

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

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

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

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

Dieffenbach, ‘Die operative Chirurgie’ (1845).

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

Op. cit., p. 55.

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

‘Trans. Path. Soc.,’ xxxviii, p. 446.

‘Bull. de Soc. Anat. de Paris,’ December, 1883.

Ibid., April, 1886.

See p. 52.

‘Medical Times,’ 1862, p. 402.

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

‘Trans. Odont. Soc.,’ vol. xx, p. 90.

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

‘Archiv f. klin. Chir.,’ xvi, p. 684.

Ditto, xx, p. 396.

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

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

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

‘Odontological Trans.,’ 1887, p. 105.

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

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

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

Op. cit.

‘Wien. klin. Wochen.,’ 1889, ii, p. 520.

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

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

‘Gaz. des Hôpit.,’ 1870, liv.

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

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

‘Brit. Med. Journ.,’ 1863, i, p. 412.

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

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

‘Deutsche Zeitsch. für Chirurg.,’ 1885, p. 205.

‘Congrès Franc. de Chir.,’ 1888, p. 480.

Op. cit., p. 5.

‘Insanity,’ p. 442.

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

‘Trans. Odontological Soc.,’ 1872, vol. iv.

‘On Oral Deformities.’

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

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

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

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

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

Vicq d’Azyr, ‘Œuvres,’ iv, p. 159.

‘Philosophical Trans.,’ 1869, p. 166.

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

The dotted line from e is erroneously prolonged a little beyond the suture.

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

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.

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

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

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

“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.

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

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

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.

Kölliker, op. cit., p. 369.

Biondi, op. cit.

‘Langenbeck’s Archiv,’ xl, p. 795.

‘Trans. Med.-Chir. Soc.,’ 1845.

Churchill, 3rd edition, 1881, chap. vi.

Op. cit., p. 109.

‘Archiv f. klin. Chirurg.,’ v, p. 52.

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

‘Deut. Zeitsch. für Chir.,’ xix, p. 15.

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

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

Op. cit., p. 39.

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.

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

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

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.

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.

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

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

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).

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

‘Journal de Malgaigne,’ Jan., 1843.

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

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

‘Archiv,’ vol. ii, p. 230.

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

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

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.

‘Lancet,’ vol. ii, 1852.

Graefe, ‘Hufeland’s Journal,’ 1816.

Roux, ‘Mémoire sur la Stapyloraphie,’ Paris, 1825.

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

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

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

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

‘Brit. Med. Journ.,’ 1890, ii, 950.

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

Wolff, ‘Berl. Klin. Wochensch.,’ 1889, p. 577.

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

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

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

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

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

INDEX.

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

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

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

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

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

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

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

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

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

Jaw, treatment of aperture after removal of upper, 145

KÖLLIKER on dentition in alveolar harelip, 52

KÖNIG, operation for unilateral harelip, 89

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

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

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

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

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

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

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

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

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

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

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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