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Original copiaa in printad pap9r covara ara filmad baginning with tha front eovar and anding on tha laat paga with a printad or illuatratad impraa- sion. or tha bacic covar whan appropriata. All othar original copiaa ara filmad baginning on tha first paga with a printad or illuatratad impraa- sion, and anding on tha laat paga with a printad or illuatratad impraasion. Tha laat racordad frama on aach microVicha shall contain tha symbol —»•( moaning "CON- TINUED"), or tha symbol V (moaning "END"), whichavar appiiaa. L'axamplaira filmA fut raproduit grica A la gAnAroaiti da: Medical Library McGill University Montreal Laa imagaa auh^antaa ont Ati raproduitaa avac la plua grand soin, compta tanu da la condition at da la nattatA da l'axamplaira filmA, at an conformity avac laa condltiona du contrat da filmaga. 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Tha following diagrama illuatrata tha mathod: Laa cartaa, planchaa, tablaaux, ate, pauvant Atra fiimia A daa taux da rMuction diff^ranta. Lorsqua la documant aat trop grand pour Atra raproduit an un saul clichA, il aat film* A partir da I'angia aupAriaur gaucha, da gaucha h droita, at da haut an baa, an pranant la nombra d'imagaa nAcaaaaira. Las diagrammaa suivanta illuatrant la mAthoda. ire. C.; ^ ,i ■• ^:..-t :^ ] 1 4 § t^ ^ Aj?. -v k ~>x C'7^ I'U A LECTURE ON THE CAUSES AND TREATMENT OF HARE-LIP DELIVERED IN THE POST-GRADUATE COURSE, JUNE, 1898. BY FRANCIS J. SHEPHERD. M.D., CM., Prolfssdr of .\iuiloiiiy, Mc(iill I'liiversity ; Surgeon to the Montreal General Hospital. Ri))rit\tv<} ffum the Montreal Medical Journal, ,Tanur<ry, IS!)!). 'I'^Ji ■ A LECTURE ON THE CAUSES AND TREATMENT OF HARE- LIP DELIVERED IN THE POST-GRADUATE COURSE, JUNE, 1898. BY Fbancis J. Shepherd, M.D., CM., Professor of Anatomy, McGill University; Surgeon to the Montreal General Hospital. Gentlemen : — Before describing the treatment of the deformity wbif'i I am to speak of to-night, I slionld like to give you a short account of the development of the face, for all the congenital deformi- ties met with are due to an arrest of this development at an early period of fcetal life. A study of embryology is of great assistance to the surgeon in enabling him to acc(junt for many of the congenital conditions he not infrequently meets with. Pr. ^toft.- Globular extremity of the medial nasal process. 3/.r.— Maxillaary arch. ^ il/».— Mandibular arch. //^.(/.— Hyoidean arch. /<»*.— First branchial arch. Development. — At a very early period of fo'tal life a series of clefts (branchial) appear on the side of tlu; cephalic extremity, separated by rods of tissue called branchial or (jill arches. The clefts conmiunicate with the alimentary canal. The tir.st branchial cleft is between the mandibular and hyoid arch(;s. The mandibular arch which is after- wards developed largely into bone is divided into the superior and inferior maxillary portions. The two sides of the inferior max- illary portion early unite to form ^he lower jaw, but interposed between the two superior maxillary portions is the fronto-nasal pro- coss. The space between the superior and inferior maxillary portions is called the buccal cleft. This is closed early except where the aper- ture remains for the mouth which is largci' or smaller according' as the cleft is more (macrostoma) or less (microstoma) closed. Some- times the buccal cleft remains open from (?ar to ear. Now as to the nasal processes, these are divided into mes'ud and lateral ; the mesial processes are united at their base by a depresseil median part the frunto-nnsal pwccHS, but below they are separated and each ends in a globular process (diagram ami slides exhibited). These nasal pro- cesses, as development proceeds, extend backwards and along the embryonic roof of the mouth forming the nasal laminte. Eventually, the nasal processes coalesce in the middle line and form the intermax- illary process and the middle part of the upper lip, the depression between forms the septuu) of the nose and by a coalescence of the nasal laminiB the rest of the nasal septum is formed. In rodents the notch between the globular processes persists and there is a fissure leading through the upper lip to the mc",;h Al)ove the depression is a triangular space forming an angle with it, this forms the tip of the nose and the triangular surface above it, the bridge. The lateral nasal processes form the alfe nasi, these are not .so prominent as the mesial. Between the lateral nasal processes and the maxillary pro- cess the lachiynial groove passes from the eye to the nose. Where the maxillary process of one side does not coale.sce with the globular proce.ss then single hare-lip I'esults, and if the union fails in the bony part as well, cleft palate is tlu'U .seen. When lioth maxillary proce.sses fail to unite with the globidar |)roee.s.st's, double hare-lip results, in this case the c'eft usually i^oes through the line of union between the intermaxillaiy and superior maxillary Itone.s. The middle pai-t of the lip thus floats free and has attached to it the two intermaxillary bones, and is itself hanging from the septum of the no,se. A failure of the two globular processes to unite is very rare though from time to time cases are reported. The mesial or septal part of the nose is developed from the junction of the globular processes. The septum is at first broad and depresscl nvA the nostrils are widely separated) as .seen in the lower races of mankind and monkeys. The median union of the palate is completed about the 10th week of f(etal life and the globular processes unite with the maxillary al.so very early, the incisor foramen only remains to mark the junction of the.se structures. The fact that the arrest of union oi these proce.sses resuiL.T in hare-lip and that the union takes place ,so early, rather dis- credits the a>anv stories one hears of hare lip find other deformities being produceii by maternal im[)ressions. In many cases the ternlen- cies to such defonnitics runs in f;iniilios and it is not uncommon for two chiMivn in one fVuiiily to sntti'V from liar(>-lip and clot't palate. Havo-lip tlicn is a con^'enital affection and often is due to lieredity. Tliei-e are vai'ious foi-ms of this deformity : 1. .Simplest, merely a notch in the red edge of the lip. 2. Throuoh the soft parts only and not <j;oin>j; throno'h to the nostril- :i. The cleft throun^h the lip anu nostril and accompanied hy cleft palate. 4. Double hari!-lip, with a floating intermaxillary bone and cleft palate, occurs in ,',j of all cases. , There art^ other i'oi'ms of deformity connected with ari'est of deve- lopment of face, such as enlarij,ement of month, a persistence of the lachrymal groove, kc. (Slides shown of these deformities.) Single hare-lii) is usually on the left side, and is always to one side in the line of the junction of the intermaxillary with the maxillary bone. The child who sulfers from this deformity, as a rule, cannot suck and has to )n' fi-d with a spoon. The niother's milk should he drawn and used as food for the child. Some advocate injecting the milk into the phaiynx with a glass .syringe, to which is attached a piece of rubber tubing. Sometimes a stoppei-ed bottle with a large teat, having the apei-ature below, is useful. Uul)bing the shild with codliver oil oi- olive oil if it is puny, may help to keep ^'t in ccmdi- ticn until old enough for operation. Artificial foods .should not be fdven unless under dire necessity. The child should be k.^pt warm in fiannel. Best A(/e for Operation. — This depends on the condition of the child and the character of the deformity ; should the deformity involve only the soft parts and the child be healthy, operate at once for the mother's sake and in order that the child may suckle. In simple cases the earlitn- the opei-ation the better. The only danger in early operations is from htsmorrhage, young children do not stand the loss of blood well. On the other hand they soon make up lost blood. Should the child be weakly, or the fissure l)e double and extend through the hard parts, then the operation ought to be po-tponed some weeks or even month.s. From six weeks to three months is probably the proper time for operating. I prefer the age of six weeks, this is well befor(> dentition has commenced. Some advise waiting in the dilficult cases until the child is weaned, but this is keeping a deforniity before; the family too long, ami furthermore it renders the success of the operation nioi-e difficult. Operatiov. The ninnl)er of operations devised for the relief of this defovmity nre many and varied. The ingenuity of surgeons is taxed more by these plastic opei-ations than by any others, and tlie number of methods is only equalled by the great variety of procedures advo- cated by the gyna3Cologist m sewing up th(( abdominal wound. Chloroform is the best anaesthetic in l \se cases. The child should be wrapped in a sheet or large towel, so that the anus may be con- fined, and than held in the arms of a strong nurse. A good light is essential. Sitting in front of the patient, the operator should first cut through the mucous membrane attaching the lip to the gum, and freely separate it so that the lips hang loosely ; the edges of the cleft are now freely pared by using a narrow-V)ladcd knife and ti'ansfixing the edge of the cleft well up to the nostril, the flap is cut free above but below it is left on each side attaclu'd to the edge. As the two eib'es of the cleft are seldom the same length, one being usually dis- tinctly longer than the other, on the longer side the soft parts should be more freely freshened ; both Haps should be cut as fur as the red line of the lips. Some advise cutting the flap of the shorter side quite away and only leaving the long one, and then bringing this flapacro.ss the middle line to fill the deficiency of the shorter side. Any I'cdun- dancy can be cut off without trouble. It is my custom not to separate the flaps from the edges of the cleft below until several sutures have been placed in the lip above and the fastened (idges of the cleft accurately adjusted near the nose. Now th(! paring from the shorter aide is cut away and more or less, as occasion recjuires, of the tissue at the red portion of the lip removed, the flap of the long side is brought over as Ijefore and adjusted as accurately as possible. By this means there is less hsemorrhage and no mistake of taking too much or too little away is made, Of course, during the operation an assistant compresses the sides of the cleft with his fingers, and thus loss of blood is prevented. Should any blood get into the mouth it must be at once removed with sponges on handles. Now as to sutures : formerly wire and hare -lip pins were always used. At present we employ nothing but silk- worm gut and horse hair. For years I have used nothing else and with the best results. Care should be taken not to go through the lip whilst suturing, but to dip down to the mucous membrane only ; the stitches should range on each side at least one-eighth of an inch from the edge. It has always been my custom, if the sutures have not been satisfactorily placed or seem to pull too much, or if perhaps there is a slight unevenncss, to immediately' take them out and re-introduce them. A little painstaking at this step of the operation is worth a good deal. After the; main sutures of silkworm gut are placed, intermediate ones of horse hair may be inployed, and afterwards the lip everted and the mucous membrane i i sutured in the mouth, by this means tlie continuity of tlie surface is preserved amJ septic matter is prevented from enteriufj the wound from the mouth. To recapitulate tlicn. The most important jioints to Vi(! observed in the oj)eration ai-e : 1. Freeing tlie lip from the gum. 2. A free sacrifice of the edge of the cleft. 8. Accurate apposition of the parts. The dressing should be simple. I usually apply an antiseptic paint (made of ioiloform. resin, oil and alcohol) put on a piece of lint or cotton and nothing more. If the usual cheek straps are applied to pre.serve tension, they should be made of diachylon plaster, which is less irritating than the rubber adhesive, and the checfk parts cut broader than the pai't running acros.s the lip, they should intei-lace in the middle line, the cheeks Ijeing well pulled forward. Before operation it is very important to know that thi; child has not l)een exposed to any fevei-s, as measles, or scai'latina. Thi.s is one cause of failure. Another is the inordinate ciying of the child, and also the too early I'einoval of the stitche.s. Sepsi.s, of couivse, i.s the great cause of failure and this is most likely to occur in badly nourished infants with pool* resisting powers. It is very important that sutures should not be removed too soon. In the old days of hare-lip pins they were removed in from 24 to 48 hours, because if left longer they would cut through the soft tissues of the infant's lip. Now we commonly leave silkworm gut in from 6 to 10 days. Should primary union not occur, wait until the in- flammatory action has subsided and then freshen the edges and bring them together. Union now almost always occurs, because the parts have become, so to speak, immune. After the operation the child should be closely looked after. There is often great difficulty in breathing through the nostrils owing to tension on the upper lip and compression of the nostrils, and rubber tubes introduced are often a great aid and prevents collapse of the nostrils. After a time the parts get eased and the child will breathe easily through its nostrils. The operation 1 have already described is that for single hare-lip. Double hare-lip is less common and must be somewhat ditferently dealt with. Where there is no projecting intermaxillary process, the operation is not difficult, 4or then all the mucous membrane from the central portion is cut aw^ay and the flaps taken from the sides of the cleft as in single hare-lip. The central portion is sutured on each side to the lateral clefts and the .ral flaps run across to meet each other below the central portion, the lower part of which is freshened. What is in excess is cut awny. Sometimes the central portion may be cut into the shape of a V and the lateral ftaps adjusted to it. In thos(! cases, however, where tlie intermaxillary hone projects the. case is rendered umch more difficult. In some ca,ses, such as where the Ixmo grows from the tip of the nose it mu.st he .sacriHced, hut usually it can ho l)rol<en hack and forced into the cleft. Sometimes it is necessary to pare the edges of the gums, and I have been obliged in some cases to keep the bone in position with win! or silk sutur(>s, It has been ol>jfcted that the incisor teeth which belong to this pre- maxillary portion grow in crooked, if .so they can be afterwards straight^'ued by a dentist, or the teeth may be pulled out. It is also objected that the retention of the intermaxillary keeps open the palatal cleft. Always try and save the intermaxillary l)one ami so prevent a gap in the soH<l jaw. In cases where I have had to remove this bone, however, there was remarkably little ileforndty. Sometimes there >s a double hare-lip and only a single cleft in the bone. In such cases th.! l)oi»y cleft of one side prcjccts and has to be forced back with the thumb. In severe cases of operation in very weak infants where much paring has to be done, and the bleeding is excessive, the final stages of the operation may have to be postponed until recovery from shock takes place. In very young children bleeding is a factor which must be considered. (The different methods of operating were then describe.l, such as Malgaigne's, Nelatons, Mirault's, Giralde's, Hose's and many others. All were illustrated by lantern slides.)