Fig. 13.

"Case-The accompanying tracing represents the exact size of a cleft of the hard and soft palate in a boy, aged 7 years, of Fort Collins, Colo., closed at a single operation, December 23, 1886, at Denver, assisted by Dr. J. M. Norman, dentist, Dr. P. V. Carlin, and others."

The brief mention of the above published cases is quite enough, perhaps, about cleft palate for the purpose of this "exhibit," which is intended to be suggestive of some former work of this sort, rather than fully explanatory.

Two other Colorado cases of cleft palate of later date were especially satisfactory in their results, but are not publishd. One of them was a boy 3 or 4 years old (operated June 21, 1888), in which case the result was perfect. He was the son of Mr. M., a resident of Denver. Dr. Geo. H. Gibson assisted me, and Dr. A. A. Clough gave ether. The other case was kindly sent to me by Dr. A. Stedman of Denver, and was operated May 19, 1892. Dr. J. M. Norman, dentist, and Dr. Geo. H. Gibson assisted me. Dr. H. W. McLauthlin gave ether. This case was also that of a boy about 4 or 5 years of age, and the son of a well known resident of Denver. The result was quite satisfactory.

These two cases just cited were not essentially different from the published cases here preferably selected for reference.

EXHIBIT TWO.

DOUBLE HARELIP.-A HIDEOUS CONGENITAL DEFORMITY.

THE WRITER'S CASES SUCCESSFULLY CORRECTED BY SURGICAL OPERATIONS.

Typical illustrations to give an accurate idea of the usual appearance of this deformity, showing front and side views.

"Remarks on the Management of the Inter-Maxillary Bone in Double Harelip," is the title of a paper read by me in 1873 before the then infant Medical Society of Colorado, and published in its "Transactions." This paper seems a useful record of experiences of double harelip. Very few copies of the "Transactions" of this society of that year are now in existence.

A strong constraining influence causes me to omit most of the practical details contained in that paper, and to be content to give a general notion only of the very satisfactory surgical relief that may be afforded for such hideous deformities.

This paper also concerns a matter of American priority in a useful surgical operation, first, as regards Dr. J. Marion Sims, and second, as regards my own labors that preceded those of some French surgeon. My own

efforts were suggested by Dr. Sims' case published in one of the far back numbers of the American Journal of the Medical Sciences.

The projecting snout, which is the inter-maxillary bone, covered with a bit of lip and gum, Dr. Sims was the first to fix in its proper position with silver wire, and, probably, the writer was the first to imitate his example with excellent results.

The fissure on either side of the inter-maxillary bone is one of the strange freaks of nature at an early period before birth; indeed, is an arrest of development, and becomes a cause of much painful interest to the parents and friends of the child afflicted with this deformity, and of perplexity to the medical attendant of such cases.

(It has been the custom heretofore, and is at present, to cut out a wedgeshaped piece at the posterior surface of the inter-maxillary bone, to break it with the thumb, and to press this bone backward in a line with the rest of the alveolar arch, and rely on the harelip operation alone to keep the bone in place. Every surgeon cannot fail to notice how inefficient this procedure proves to be. Some time after having used silver wire in such cases, my attention was attracted to an account of some cases published in the Bulletins de la Societe de Chirurgie of Paris, in which silver wire was used to fix in its proper place, with bone sutures, the inter-maxillary bone. This operation was trumpeted as a new one, but the credit should be given to Dr. Sims.)

The ugly projecting snout of bone, with a hideous fissure on either side, often accompanied with a cleft of the palate, is continuous behind with the bony partition of the nose.

A wedge-shaped piece of bone is required to be cut out behind this snout, to allow it to be broken at its constricted part and pushed back to its place.

This snout, much enlarged, rounded at its free end and constricted at its base, containing in older children the front teeth of the upper jaw, is covered with a bit of upper lip and is turned upward.

In most cases, the rounded part of the snout is wider than the space between the two maxillary bones of the upper jaw; the inter-maxillary bone being the snout, which by a freak has refused to follow the orderly course of nature and join its companion pieces of the upper jaw.

This snout should be pared as also the near edges of the upper jaw pieces, before the inter-maxillary part can by the surgeon's art be adjusted in place and fastened with silver wire. After this, immediately follows the harelin part of the operation.

A first case of this sort was not my own, but during the operation I suggested, and by request of the operator, applied the silver wire bone sutures. This case was of a child, aged 1 year, which Dr. J. P. P. White of New York desired me to see with him, and afterwards requested my assistance in the operation, which was done some time during the year 1870.

The second case was one upon which I operated April 20, 1871, assisted

by Drs. J. C. Warren and A. Landeta of New York. The little patient, aged about 3 months, had the usual horrible deformity caused by cleavage in two places of the front part of the upper jaw, and the characteristic bony snout projecting far out in front.

The third case was brought to me at New York from Baltimore. This little patient was 6 weeks old, and offered a peculiarity which the preceding one did not; which was a more extreme degree of projection of the intermaxillary bone, and a very great projection of the front part of the bony partition of the nasal cavities.

The operation was done on the 6th of May, 1872, assisted by Dr. Fred A. Burrell of New York. I cut, with a pair of properly curved scissors, a large wedge-shaped piece of bone from the vomer; broke and pushed the inter-maxillary bone into its proper place, having previously pared the edges of this bone and the corresponding parts of the upper jaw; the little patients in each of these cases being under an anasthetic which made them insensible to pain.

This time, "it was required to take a flap from high up within the nostril of the left side, and transfer this flap to the lower right border of the lip, so as to form a vermilion border for the lip below the bit of skin which covered the front surface of the inter-maxillary bone."

An inspection of the figure seen from a front view will facilitate the understanding of this transposal of flap. "This procedure also had the good effect to lessen the width of the nostril on the side from which the flap was taken. As Langenbeck has pointed out, a very important influence is thus shown to obviate, to some extent in after years, the nasal tone by lessening the width of the nostril during the harelip operation."

The results of the double harelip case from Baltimore and of the preceding one, were very satisfactory.

If the inter-maxillary bone be removed, its loss will be apparent later in life, when the rest of the upper jaw becomes more developed. The upper jaw will then present a wedge-shaped appearance and deform the features. Such was the case in one of my cleft palate patients sent to me by Prof. T. Gaillard Thomas of New York,-the case from Richmond, Va., already mentioned in my exhibit of cleft palate cases.

EXHIBIT THREE.

TWO CASES OF REMOVAL OF HALF OF THE UPPER JAW FOR TUMORS.

Case One-Removal of the right half of the upper jaw for a bony tumor in a negro girl, April 15, 1865, at Anderson, South Carolina, aged 12 years. See New York Medical Journal No. XV., Vol. III, 1866, with illustrations as at figure 2 of that journal. Operated at the request of Dr. P. A. Wilhite of Anderson.

At the time of this operation the writer was on duty as a surgeon of the Confederate States army in that part of South Carolina, examining conscripts and disabled soldiers, and received for his operation, from the humane master of this negro servant, a desirable fee in bacon and corn. Sometimes the surgeon receives for his wages, neither corn, bacon, nor ducats, and indeed is happy with success alone. The proffered fee in bacon and corn was right gladly accepted because these articles of food could be used in barter. At that time the writer had but scant funds other than the almost valueless Confederate currency of the tottering, falling, dear old Confederacy of the South-a Confederacy aged and worn out by four years or incessant depredations, of. fierce battles, and of starvation; a Confederacy forever memorable for its valiant and stubborn defense, for its gallant soldiers, for its brave and enduring people; a God-fearing, truth-loving, sturdy and honest Anglo-Saxon people, who are his people, whose "lost cause" was his cause, and who, he believes-the sensible ones at least, and the bravest onesfaithfully accept, as he accepts, the result of our great civil war, now believing, though, may be, not at first, that it was best as God willed it.