On harelip and cleft palate

by William Rose

We must now turn to the functional results of these deformities, and trace out some of the effects which they produce on the economy.

Fig. 44.—Soft metal cover to teat of feeding bottle, which can be moulded to the infant’s mouth, and act as an obturator during suction. (Mason.)

We necessarily place in the front rank the serious difficulties met with in the administration of nutrition. Where the lip alone is involved, and that only to a slight degree, but little difficulty arises, as the child is usually able to suck; but in the severer cases of cleft lip, involving also the alveolus and palate, the child’s life may be endangered from the inability to take or to swallow sufficient food. For as the cleft alveolus and lip seriously impair the power of suction, so the cleft palate allows the fluid which has found its way into the mouth to regurgitate through the nose. In many such cases spoon-feeding is the only chance for the child. To carry this out successfully the head must be thrown well back, so that the fluid may pass directly into the pharynx; in fact, the child is often obliged to drink like a bird, in which, as is well known, the communication between the mouth and nose through the non-union in the median line of the palate bones necessitates a similar manœuvre. But even when this precaution is taken, there is no doubt that many infants with fissured palate die of sheer starvation. Mr. Mason suggested the use of an apparatus such as that figured below ([Fig. 44]). It consists of an ordinary india-rubber teat attached to a feeding bottle. Over the teat is a very thin plate of soft metal, which can be readily moulded to fit the infant’s mouth, and so act as a temporary obturator. It may be used with advantage in some cases, but I have not employed it largely, preferring to trust to careful spoon-feeding. A similar contrivance in india-rubber which can be fitted to a Maw’s feeding bottle has been successfully used. A covered spoon with apertures left at either end is, in the hands of an intelligent nurse, an efficient contrivance.

Coles has devised an artificial palate attached to a shield to go over the mother’s breast ([Fig. 45]) in order to enable the infant to take its natural nourishment. It is made of thin elastic rubber, is not uncomfortable, can be kept perfectly clean, and from the shape in which it is made can be used for either breast. In exceedingly delicate children the employment of this device may be advisable.

Fig. 45.—Nipple shield suggested by O. Coles for use in cases of cleft palate. A is the apparatus fitted to the breast, and prolonged anteriorly so as to form a shield, which projects over the nipple. When in the child’s mouth it acts as an obturator, partly shutting off the nasal cavity. (Coles.)

In the severer cases it must not be forgotten that it is quite possible that some other factor is engaged in the production of the rapid wasting which in spite of every precaution may ensue, such as mesenteric tuberculosis, or some congenital intestinal or vascular defect. Whether such exist or not, the child quickly emaciates, the face becomes pinched and old-looking; the skin has an earthy appearance and hangs in wrinkles, lax and inelastic; and death, practically from starvation, soon ends the chapter.

When our patient survives the dangers of infancy and arrives at boyhood or girlhood, the regurgitation of food through the nostrils ceases, except under occasional circumstances or in very severe cases; and although the difficulties of infant nutrition are often manifested in a much retarded growth, yet there is no reason why the physical constitution of the patient should ultimately suffer. Again, the knowledge of such visible and audible defects before operative treatment has been undertaken has a decidedly depressing influence upon the mind. The subjects of this deformity, from evident consciousness of their repulsive aspect, shun the observance of others as they grow older; and so strong is the sentiment which prevails as to maternal impressions that they are studiously avoided by women in the earlier stages of pregnancy. I have often noticed a distressed or hunted expression on the face of those who had attained to adult life before surgical treatment had been undertaken; and its disappearance after a successful operation has been equally marked.