Left-sided cleft palate.
The coincidence of cleft palate with hare-lip has been described. (See [p. 645].) While they often are combined, either may occur without the other ([Fig. 467]).
Fig. 467
Left-sided hare-lip and cleft palate. Marked displacement of intermaxillary bone. Boy, aged six years. (Bevan.)
No matter how incomplete the palatal cleft may be the nose and the mouth are converted into a common cavity. Suction, as from the breast, is impossible. Infants with this defect should be carefully fed by hand; as they develop, food passes readily from the mouth to the nose, while there is corresponding difficulty in swallowing. With lapse of time speech becomes defective or almost unintelligible. There is, therefore, every reason for any possible closure of such defects. Against the mechanical difficulties on one side should be weighed the desirability of such closure on the other. One argument advanced in favor of operation on hare-lip is that the influence of the pressure thus afforded will tend to hasten the natural attempt on the part of the halves of the upper jaw to grow toward each other instead of in the opposite direction. On the other hand, by closure of the labial defect, the space within is materially diminished and manipulation made more difficult. It then becomes a serious problem when to operate upon a given case of cleft palate. The operation itself is usually one of no small mechanical difficulty, the space required for manipulation is most restricted, the procedure relatively a long one because of the anesthetic, and necessity for its frequent suspension in order that the operator may proceed, and, because of these difficulties and delays, the attendant shock to the patient. A puny child, unable because of the defect to take sufficient nourishment, is then in far from a favorable condition for a serious operation. Without a general anesthetic no child will endure it, while local anesthesia in the young is insufficient on account of their timidity and involuntary resistance. When to operate, then, should depend upon the condition of the child, the dexterity of the operator, and the width of the cleft—that is, the amount of work to be done.
Brophy, of Chicago, has taken a radical and advanced position in this matter, and believes that these operations should be performed in early infancy, a fact which his own large experience would appear to demonstrate. Yet this same experience has developed in him a facility possessed by few, and that which such an operator may do with impunity can be duplicated by but few. He finds, however, unanswerable argument in this: that in infancy the bones of the jaws are scarcely developed, are not only friable but very flexible and yielding; that even in the very young the tissues unite kindly, and that very young infants seem to be less liable to extreme shock than those several months old; that the earlier the muscles of the palate are brought into contact and action the better performed are the functions of deglutition and of speech, and that if they are not used they atrophy; that the teeth are more likely to erupt normally, and that the extreme liability to pharyngitis produced by such wide-open fissure is obviated. To all of these statements no objection can be raised, and the only argument which can be adduced against Brophy’s position is the actual danger of the operation.
In the matter of time it may be said that in extremely competent hands operation in infancy is the ideal method, but that when children reach the age of two or three years and still have very small mouths, not much is lost by waiting until they are five or six years of age, while considerable room is gained for ease of manipulation. Much depends also on the temperament and obedience of the child. These children, like most of those born with congenital defects, are usually pampered and spoiled by indulgent parents, so that at a time when implicit obedience is most needed it seems almost impossible to do anything with them. In dealing, therefore, with such a child one should insist upon its being thoroughly disciplined, and, at the same time, accustomed to manipulation within the mouth, as the presence of a finger, tongue depressor, etc., so that when need comes for their use the child shall not be totally unaccustomed thereto. Every case should also be prepared so far as possible by antiseptic and astringent mouth-washes. A nasopharyngeal catarrh which shall compel such a patient to be constantly swallowing and spitting may defeat the object of the operation itself.
The terms usually used in this connection are uranoplasty, which means closure of the hard palate, and staphylorrhaphy, which means the closure of the soft palate.