On harelip and cleft palate

by William Rose

Management of the Patient after Operation.

The patient should be placed in bed with the head low and no pillow, so that any oozing or accumulation of mucus, whether from the upper or lower surface, may gravitate into the pharynx; otherwise it may insinuate itself between, and tend to separate the lips of the wound.

A certain amount of shock is frequently observed during this period, and the circulation in the extremities should be promoted by warmth. A shivering fit, scarcely amounting to a rigor, is often observed, but is of no prognostic importance. During reaction, the blood which has been swallowed during the operation is usually vomited; when this occurs early the danger to the palate is not very great; but any vomiting at a later period has a serious disturbing effect, and the greatest care must be exercised in the supervision of the diet and general hygienic surroundings in order to prevent such accidents.

Diet.—It is best to give no nourishment for the first three or four hours, and but very sparingly for the first twenty-four. Iced milk and water, or milk and soda-water, given in small spoonfuls, should be the first food supplied; but after twenty four hours, when the tendency to vomiting has disappeared, the food should be slightly warm. Milk and water given by spoon or from a feeder at frequent intervals will form the staple article of diet; but if the patient be rather older, strong broths and clear soup may be added. By the fifth day they may often safely take soaked bread, custard pudding or some soft farinaceous food; but no hard substance, liable to damage the newly-formed adhesions, should be allowed for fully a fortnight.

If the patient be sufficiently intelligent, it is advisable that the mouth should be gently washed out, especially after food, with a tepid weak boracic solution. This is best effected by using it as an ordinary gargle; syringing the mouth I consider to be unadvisable, because the jet if forcible will tend to find its way between the margins of the wound, and hinder union. Some surgeons recommend that prior to fastening the stitches during the operation, the edges of the wound should be touched with a solution of chloride of zinc in order to assist in keeping them aseptic; this is really unnecessary if careful washing of the mouth after the operation be enjoined.

Of course absolute quiet is essential, and all attempts at talking must be strictly forbidden. The child should be closely watched, and any attempt to meddle with the palate should be prevented by tying down the hands, which may be done as a matter of precaution throughout the whole duration of the case with young children, and as a routine during sleep with all patients. If the child is noticed to suck at the palate, or curl the tongue up against it, an effort should be made to divert its attention.

The palate should not be examined too often. The blanched appearance observed at the close of the operation generally disappears during the first few hours, and a moderately injected condition of the mucous membrane with slight swelling of the palatal tissues is a sign that all is doing well. The lateral incisions usually fill with granulations rapidly, and these subsequently cicatrise; the rate of their healing depends on the width of the aperture and on the vitality of the patient.

It is impossible to lay down any hard and fast rule as to the period when the stitches should be removed. In the majority of cases where the course has been satisfactory the stitches in the velum may be safely removed on the sixth or seventh day; those in the hard palate, if causing no irritation, had better remain a little longer. If there is any doubt as to the firmness of the union, the sutures should not be touched till later, as they seldom of themselves give rise to any trouble. It occasionally happens that a child refuses to open its mouth, and renders removal of the stitches without the chance of damaging the palate impossible; an anæsthetic must then be administered.