Cleft palate

“ 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) . ”

“ But, assuming that the infant is in fair health, that he is taking his food well and thriving on it, that he is not troubled by vomiting or diarrhoea, and that the hare-lip is not associated with a defective palate, the sooner it is operated on the better. It may be successfully done even within a few hours of birth. When a hare-lip is unassociated with cleft palate, the infant may possibly be enabled to take the breast within a short time of the gap being closed. ”

“ Harelip—Cleft palate—Frequency—Occurrence in animals—Associated deformities—Median harelip—Facial clefts—Macrostoma—Mandibular clefts—Causes of these deformities.
The congenital fissures and deformities of the mouth and lips form a group which is considerably larger than might be imagined from the scanty notice given them in ordinary text-books; and although many are extremely rare, yet possibly if more attention were drawn to them, fresh cases would be noted and recorded, and the somewhat scanty materials from which we have to work out their development and characteristics would be increased. ”

“ This leads to various deformities, the chief of which are cleft palate and hare-lip. Cleft palate has been known to affect several members of the same family, and to occur in the offspring of the affected members. There are instances of the transmission of this deformity from an affected pug-bitch to her offspring. If it were possible to practise selective breeding in man as in dogs a race of men with hare-lips and cleft palates could probably be produced. ”

“ The foramen incisivum (anterior palatine foramen) marks the point at which these elements of the palate unite. The process of fusion begins in front and spreads backwards, the two halves of the uvula being the last part to unite.
As development may be arrested at any point, several varieties of cleft palate are met with. The uvula, for example, may be bifid, or the cleft may extend throughout the soft palate. In more severe cases, it extends into the hard palate as far forward as the foramen incisivum. In these varieties the whole cleft is mesial. ”

“ Incorporated with it are five pairs of muscles, controlling its movements; it is covered by a smooth thin mucous membrane, and terminates posteriorly in the uvula. The arrangement of these muscles is important, not only from their normal physiological functions, but also from their irregular action and effects in cases of cleft palate (Fig. 28) . They may be arranged in groups: two, the levator and tensor palati, form a superior group; the azygos uvulæ is intermediate; and the palato-glossus and palato-pharyngeus form an inferior set. ”

“ Infants born with a cleft palate cannot suck from an ordinary bottle, as the deficiency in the hard palate prevents the necessary vacuum being formed in the mouth. Such children are, therefore, usually brought up with a spoon, and often waste and die through insufficient nourishment. ”

“ The imaginary “maternal impression” probably in nine cases out of ten has nothing to do with the defect; whilst a real “maternal shock” which possibly led to the production of the deformity passes unnoticed. Mr. Carless tells me of a case recently seen by him of a cleft of the soft palate in a child, whose mother, without asking any leading questions, gave a history of a sharp attack of febrile disturbance keeping her in bed two or three weeks at a period when the fœtus could not have been more than two months old. ”

“ Other associated malformations are on record, e. g. an extra thumb on each hand; and Sir Morell Mackenzie has reported a case in which there was a congenital fissure between the arytænoid cartilages with a trilobate epiglottis, occurring in conjunction with harelip and cleft palate. [12]
The remaining deformities to be noticed here are much less common, but demand attention by their rarity and interest, and on account of the light they throw on the embryology of the lip and mouth. ”

“ In regard to cleft-palate Fergusson’s labours were of even greater value, for he discovered by careful dissection the reason [Pg 78] why the edges of the wound were so often prevented from uniting, and by dividing the muscles concerned, in addition to other valuable improvements in practice, he enabled many patients to gain an excellent undivided palate. Up to 1864 he had operated on 134 cases, of which 129 were successful, and only two failed entirely. It is unnecessary to go through the long list of successes won by Fergusson ”

“ The name is really a misnomer, in that the condition (as has been many times pointed out, but notably by Fergusson) does not simulate a hare’s lip except in the fact of being cleft, for the natural [3] cleft in the animal’s lip is always in the median line below, bifurcating above to reach either nostril (Fig. 1) , whereas in the abnormal human lip the cleft lies to one or the other side. Instances of median defect are known, but they are extremely uncommon, and consist often of more than a simple fissure. ”

“ The deformity may exist as a simple notch in the soft tissues of the lip, unilateral (Figs. 2 and 3) or bilateral (Fig. 4) ; when more decided, it may implicate one or both nostrils (Figs. 5, 6, and 7) . In mild cases the alveolus is intact; in others, cleft, constituting the variety known as alveolar harelip, and the line of fissure may, or may not, extend backwards into the palate. In all cases of double alveolar cleft, the palate is also involved, and the central parts of the lip and intermaxilla tend to project forwards ”

“ A specially devised apparatus which assists the child in nursing may be found on the market, for nursing is well-nigh impossible without the closure of the roof of the mouth. The operation for cleft palate is usually successful when performed at the proper time and by competent hands. ”

“ Another frequent abnormality is cleft palate, a fissure in the palate, due to defective development.
The Teeth. These are specially important, for criminals rarely have normal dentition. The incisors show the greatest number of anomalies. Sometimes both the lateral incisors are absent and the middle ones are of excessive size, a peculiarity which recalls the incisors of rodents. The teeth are frequently striated transversely or set very wide apart (diastema) with gaps on either side of the upper canines into which the lower ones fit, a simian characteristic. ”

“ In Negligent Lisping, this inability properly to imitate correct speech processes, results in the substitution of an incorrect sound for the correct one with consequent faulty formation of words.
ORGANIC LISPING: This results from an organic or physical defect in the vocal organs, such as hare-lip, feeble lip, malformation of the tongue, defective teeth, overshot or undershot jaw, high palatal arch, cleft palate, defective palate, relaxed palate following an operation for adenoids, obstructed nasal passages or defective hearing. ”

“ But the separation of the facial elements is not always maintained; sometimes they fall or are drawn together by the united palate, resulting in the so-called congenital atresia of the nose (“angeborene Atresia der Choanen”) , cases of which have been recorded by Luschka, Bitot and Engel. The latter states that in an infant’s skull examined, only 2 or 3 mm. of space existed between the orbits, and 4 mm. between the optic foramina.
2. True median cleft of the upper lip with development of the intermaxilla is an excessively rare occurrence, but a few cases have been now recorded. ”

“ The normal shape of the palate is a regular arch, bounded laterally by the gums and alveoli into which the teeth are implanted so as to describe a parabolic curve, being normally uninterrupted at any spot by spaces or diastemata. The height and curvature of the palate vary considerably in different individuals, not only from inherited peculiarities, but also from acquired conditions dependent on the teeth. A person with a good set of sound teeth will probably own a regular well-formed palate ”

“ An examination of the parents’ mouths should always be made when possible, and very commonly it will be found that one or both possess a short upper lip, and a high arched narrow palate. In others there is a slight groove in the alveolar process between the central and lateral incisors. I have also observed a small symmetrical crease on either side of the median line in the upper lip, indicating a tendency to, if not a natural intra-uterine cure of, a double harelip. ”

“ But according to the cases reported by Trendelenburg the [14] defects do not stop here. There is usually in addition a broad median palatal cleft, and an absence of nasal bones and muscles; but Kundrat records two cases where the palatal processes of the superior maxillæ and palate bones were well developed, and united in the middle line. The skull itself has been found defective occasionally, the whole cranial portion being small, and the lamina cribrosa and crista galli of the ethmoid absent ”

“ Harelip is a congenital deformity of the upper lip, characterised by a cleft extending for a variable depth, either through the soft tissues of the lip only, or implicating in addition the alveolus, floor of the nose, and palate. ”

“ In the median line is a well-marked raphe, extending anteriorly to a prominence indicating the position of the anterior palatine canal. The rugose condition of the membrane over the hard palate is not seen in young children; it supervenes later in life. ”

“ 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 [7] 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. ”

“ Often when in such cases there is no definite history of harelip, it is found that in either one of the parents there is a very high arched palate and a thin upper lip, showing that the normal occlusion of the cleft which exists here during foetal development is not quite perfect, and this peculiarity may be traced for several generations back, with an occasional occurrence of harelip as an exaggerated example of the faulty tendency not to produce sufficient tissue in this neighbourhood for the proper closure of the embryonic cleft. ”

“ The combined action of these muscles raises and makes tense the velum, and in addition influences the Eustachian tube; but the levator is by far the more important. The azygoi uvulæ muscles arising from the median raphe and spine of the hard palate descend to the tip of that process, and are thus able to regulate its length.
Fig. 28.—Muscles of palate dissected. The cut represents the posterior nares and upper surface of the soft palate.
a. The levator palati. b. The inner bundle of fibres of the palato-pharyngeus, forming the posterior pillar of the fauces, c. The palato-glossus. d. ”

“ The vascular supply of the palate is free and abundant, a circumstance which is of the greatest surgical importance in that it permits of the free detachment of the soft structures from the hard by long lateral incisions, and the necessary manipulation of these in uranoplastic operations without any fear of loss of vitality, provided that the patient’s health and constitution are tolerably sound, and that sufficient pedicle is left in front and behind. ”

“ Its increase in length is from 20 to 30 millimetres, whilst its breadth is only augmented by 10 to 15 mm., and this mainly posteriorly. When once the permanent incisors, canines, and premolars are developed, the anterior portion of the palate alters but little in shape, unless any of these teeth be lost, and the gaps not artificially maintained.
Dr. Ehrmann [36] states that the alveolar border in front of the canine teeth forms a nearly regular semicircle, with a posterior transverse diameter of 22-26 mm.; thence the alveoli diverge regularly, adding to the diameter about 2-4 mm. ”

“ This deformity may be unilateral or bilateral (Guersant, Meckel) , more frequently the former; and is not uncommonly associated with macrostoma of the same or opposite side of the face (Guersant, Pelvet [18] ) , as seen in Fig. 20.
Albrecht [19] records a most interesting case in a newly born pup (Fig. 21) of double clefts extending from the lip margin upwards not only into the nostril, but also towards the eye on either side, i. e. a double associated harelip and facial cleft. The specimen is taken from the Royal Veterinary College of Brussels.
[18]
Fig. ”

“ Writers on the voice have almost universally claimed that the principal office of the soft palate is to shut off the nasal and head cavities from the throat, and to force the column of vibrations out through the mouth, thus allowing none, or at most a very small part, to pass into the nasal passages. ”

“ As before shown, the soft palate is constantly being used more or less, and when it and the tongue unite in action so as to cut off the mouth cavity, or, more strictly, the anterior portion of it, from the nasal chambers, a very pronounced modification in the tone results, and, of necessity, such actual escape of breath as occurs takes place through the nose. In reality, there is a special modification of the shape of the resonance-chambers for every tone produced, and especially when the color or quality is changed, as well as the pitch. ”