Cleft Palate IO o 



teeth may be found in an osseo-mucous tuft which is upon the tip of 

 the nose, and when the inter-maxillary bones are attached to the tip 

 of the nose (p. 17) the cleft is wide 

 in the extreme, as is shown in 

 the adjoining woodcut. 



The palatine ingrowths from 

 the maxilla are a comparatively 

 late development of the bucco- 

 pharyngeal cavity, and when their 

 union fails to take place, on look- 

 ing into the mouth, a view is ob- 

 tained of the bright red membrane 

 covering the turbinated bones. 

 Many infants who are thus affected 

 die of inanition, as they can 

 neither suck, nor satisfactorily swallow the milk which is poured into 

 the mouth. For feeding they should be held upright, so that the milk 

 may drop directly into the pharynx. 



If, as the child grows up, the cleft be so wide that merely a trace 

 of the maxillary plates exists, operative measures will be impossible, 

 but the mechanical dentist may eventually be able to mould a service- 

 able obturator (obturo, -am, stop up} to prevent the food entering the 

 nostril, and to improve vocalisation. 



The plastic operation for cleft-palate consists in freshening the 

 edges of the cleft, detaching the muco-periosteum from the hard 

 palate, and incising it close along the inner border of the alveolar 

 process, so that the lateral flaps may be approximated, and secured by 

 stitches. The flaps must be as wide as possible, so as to contain many 

 branches of the posterior palatine artery, otherwise sloughing may occur. 

 The apeneurosis of the soft palate must be detached from the hard 

 palate, or the halves cannot be brought together. When the cleft in the 

 soft palate has been stitched up, the halves would be drawn asunder 

 again by the levator and tensor, and by the palato-pharyngeus of each 

 side, if these muscles were not divided. Their division is best effected 

 by a bold cut right through the outer part of the soft palate, in an antero- 

 posterior direction. In my experience, the freer these cuts, the greater 

 the prospect of the success of the operation. 



In several cases lately I have operated with the child's head hanging 

 back over the end of the table, so that the blood may escape by the nasal 

 fossa and the anterior nares, rather than trickle into the larynx or oeso- 

 phagus. This position serves well also in the removal of nasal polypi 

 from the adult, especially if bleeding is likely to be free. 



Deglutition. In the first stage of the act the mouth is closed so as to 

 give the tongue and the muscles attached to the lower jaw a fixed point ; 

 then the food is pressed backwards by the tongue along the roof of the 

 mouth the facial and the hypoglossal nerves being those which thus 





