On the operative treatment of harelip / by W. I. Wheeler.

  • Wheeler, W. I. (William Ireland), 1846-
Date:
1887
    incapable of sucking. Indeed Sir Astley Cooper has pointed out the frequency of the failures he met with in his own practice, in operating on infants shortly after birth. I consider the best time is soon after the child is weaned. It is then capable of receiving nourishment independently of the mother." Dr. Houston was in favour of the third month after birth, and also Dupuytren, who thought the flesh of newly-born children too soft, and believing the needles would tear through it, and because of greater mortality than at a later or any other time of life. Syme, believing convulsions of common occurrence from the oper- ation, advised against operating immediately after birth." Chelius recommended the period of eight months; and only when the "wolf's pharynx" is along with hare-lip, and that the child could not suck, would he advocate the operation to be undertaken Avithin the first six months. Mr. South would not perform it till two years, and, if possible, would wait till the child was six years old. He thought early operations inadvisable, as the crying of the child tears through the adhesions, and an unseemly notch occurs in the lip. Lawrence, Rocca, Mestenhauser, and Sir W. Fergusson, prefer about the end of the first month. Dieffenbach advised the operation should not be performed till after dentition. Dubois, Malgaigne, Giraldes, and Abernetliy advised operation soon after the birth of the child. Guersant says that in seven operations immediately after birth he had only one failure, Avhilst in the same number at the age of one month he had five failures. Professor Dubois, before alluded to, read a paper on the subject of early operation, at the Academy of Medicine, Paris, in the year 1845, relating seven cases that had come under his observation where the operation was resorted to successfully a few days after birth. Malgaigne and others have adopted like practice; also Dr. J. Mason Warren. Sir W. Fer- gusson, in his "Practical Surgery" (fifth edition), says:—"From all my reflections and experiences on the subject, I am more than ever disposed to recommend a very early operation. Most of my patients have been under three months old." * Principles of Sui-gery. 18-12.
    It would be impossible to lay down dogmatically any hard-and- fast rule as to the exact pei'iod for operative interference in every case of hare-lip. There are circumstances that may demand an operation immediately after birth. No matter what age the child may be, if it be in need of nourishment and deprived of such by the food running out through the fissure of the mouth or through the nose, I hold it is the duty of the surgeon to operate at once, and prevent death by inanition if possible; but, should such urgent indications be not present, and that I could select a period, I would choose from tln^ee to six iveeks after hirth, and witliin three months. The earliest period at which I have operated was twelve days old, and the latest twenty-six years ; but that the operation can be undertaken at any period after a month is well exemplified in the few cases I have selected to record, and out of the entire number I have operated on I have been fortunate enough never to have lost a patient. I have not been able to see any objection to operate during dentition. I am aware that many writers direct this time to be let pass or to operate before it; but, unless there is great suffering and distress, which might be increased by an operation, I would not feel it was necessary to postpone. Of the advantage of early operative measures there can be no question. The child can take nourishment better. Many of my cases sucked from the mother with vast improvement, the needles still holding the parts together. Besides, at an early age the child is more manageable, and the structures are more amenable and more likely to approach their normal state, independently of many other obvious reasons. Should the palate be split, the joining of the lips tends to its closure. This advantage has been alluded to by Mr. Butcher in his " Operative Surgery," page 655, and is clearly verified by Mr. Henry Smith, who refers to a patient of Mr. Bateman's operated on four hours after birth, at which time the palate was so split that the mother could put her fingers into it, but in three years after would only admit the edge of a sheet of paper. I cannot understand how such an erudite and dexterous surgeon as Mr. Listen could have been so unfortunate as he records in his
    results. Mine alone are sufficient to controvert both liis and Mr. Bransby Cooper's objections to an early operation—as also Dupuy- tren's, who thought the flesh too soft for the needles. Nor can the fear of convulsions be considered a barrier, as stated by Mr Syme and Sir Astley Cooper, I have observed it but in one case (Herbert R., Case XI.), and, as there mentioned, it is unusual. But there are cases which may require to be postponed, and that for a very long period. I allude to those cases of aggravated double hare-lip, with protruding intermaxillary bones, with cleft hard and soft palate. Supposing a surgeon meets a case of this kind, the child taking its nourishment tolerably well, it may be incumbent on him to postpone performing the necessary operation for a very lengthened period—even for several years—for there may not be physique; or, even if there is, and fair development, there may not be that vital force Avithin the patient to withstand the shock of such an operation. Experience will now help the surgeon to decide whether the strength of the patient will be equal to the strain and to the demand upon it. Such is illustrated in Mary M., Case VI. Had that child been subjected to so severe a procedure as was necessary for the restoration of the deformity at an earlier age, the probability is she would have succumbed. With regard to operation there are several results to be looked for—the most important indication is to join the fissure; but there are others, in my mind, not less important. It seems equally essen- tial that the beautiful prolabial (red marginal) curve should be restored, the unsightly notch prevented, the fossa labialis formed, and the nose, whether distorted on one or both sides, restored to its proper position. Such results cannot be obtained by inexperienced hands, or by those ignorant of the anatomical relations of the mouth. Truly, surgical artistic skill is much required in this operation. I have not been able to appreciate or to see any advan- tages in the fanciful operations, such as Giraldes' mortise, M. Mirault's, Sedillot's, nor M. Henry's; indeed, they prevent the indications, as stated above, being accomplished, for the surgeon operating after their manner cannot possibly preserve the perfect curve of the red margin, nor can there be the most tension over the
    incisive fossa, so necessary to cause a slight protrusion at the lower border. Malgaigne's operation and its modifications may occasion- ally be necessary, but not to prevent the labial notch—it is not required for that purpose. If the lower needle is introduced after the manner I have described, and the edges correctly cut, no notch can exist, nor can it follow by the contraction of the cicatricial tissue, as stated by an American writer, if the marginal joining be perfect in the first instance. Nekton's operation adopted in Case IV., and there recorded, pro- duces beautiful results; but in the majority of cases that will present the cleft can be closed and the symmetry of the mouth restored by cutting the edges from below upwards with the straight or curved scissors. I am not wedded to either, but there are cases where the curved Avould be very inapplicable, and too much substance might be removed. The ellipse made by the curve has many advantages, but in careful hands either instrument will procure excellent formation. Notwithstanding the examples given of the treatment of the central lobule and the protruding intermaxillary bone, I feel a few further remarks necessary. In shaping the central fleshy piece some care is requisite not to leave any portion of the edge towards its inferior extremity uncut; it invariably suits for a columna for the nose, and has been fitted as such in the cases recorded; nor is it expedient to depress it much if not utilised in this way, as it only pulls upon and depresses the nose. With respect to the intermaxillary bone protrusion, several methods of treatment have been advised by writers on the subject— excision or removal being the practice of some, as Sir William Fergusson and Franco, bending it into the place it ought to occupy being the method used by others. There are those who condemn this latter plan—adopted by Messrs. Marjolin, Huguier, Butcher, Gensoul, and myself, with good success. Desault had favourable results from compression of the bone in eleven and eighteen days by a band fastened behind. Professor L^on Le Fort {Bulletin General de TMrapeutique Medicale et Chirurgicale, 1878) advocates the removal of the bone. Breaking the pedicle he thinks dangerous as well as inapplicable, and fears breaking the cribriform plate of the
    ethmoid bone. One tries, he says, to break the vomer by putting the weight on the intermaxillary bone, but at this point the vomer is very resistant, and one will be very much exposed to carry the fracture into its base or cribriform plate, and might thus fracture the base of the skull. Again, he thinks the bony tubercle brought backwards describes the arc of a circle too long, or, taking an oblique direction, directs the teeth behind, and the end of the nose, before flattened, is drawn back still further by pulling the tubercle, to which it adheres. Besides, what is the use of pre- serving ? The bony tubercle bears only two incisors. Again, he says, another difficulty of intermaxillary—what to do Avith the fleshy slip at the extremity of nose. The Professor comments on a case of Mr. Butcher's, and thinks the lamina that was broken must have been a very slender structure. Professor Leon Le Fort, in thus writing, does not appear to understand that in the case he alluded to the bone was half cut through, the soft tissues being preserved before any attempt was made to bend back the intermaxillary. If this course is adopted and the vomer notched, or a triangular piece cut from it, as done by Blondin, it would be impossible for a fracture to be carried where he describes—the base of the skull. And even if the teeth should be directed backwards, that is no reason for removing the bone. The teeth can be removed, and the natural support still remains for the lip; but, I doubt not, this pernicious position of the teeth could be guarded against by mechanical contrivance. As for the nose being flattened, if the central fleshy lobule is correctly dealt with, and the septum, such cannot occur. Con- trary to the Professor, I am of opinion that one of the most cogent reasons for preserving this osseous piece is because it contains teeth, and although invariably but two—the central incisors—the germs of the four incisors are in the intermaxillary bone, and the lateral incisors may develop. No, this central piece should not be taken away. In almost every case it can be preserved, bent in the manner I have recorded, held there by interosseous suture, and interrupted through the gums as well. There is sometimes difficulty in penetrating this bone on