SURGICAL TREATMENT OF CONGENITAL CLEFT PALATE.

A. P. Condon, M. D., Omaha.

ONGENITAL fissure of the palate, together with hare-lip, are so conspicuous and occur so frequently, that means toward a radical cure of these deformities have always been of much interest to the surgical world.

Cleft palate is, without doubt, one of the most unfortunate deformities that can befall mankind. The true cleft includes the velum, the hard palate, and the alveolar process with single or double hare-lip. If the inter-maxillary bones have failed to unite on both sides with the lateral or maxillary bones double hare-lip is the result; if the union has occurred on one side, single hare-lip is observed.

As to the etiology of these natural defects numerous theories have been advanced. There is, as we know, an arrest of development, but the reason for such failure on the part of Nature to close these embryonal fissures is not exactly known. Improper and insufficient diet of the mother during the early growth of the fetus; that is a lack of such foods, as meat and the phosphates which are used in the production of tissue and bone predispose to the deformities. In proof of this theory observations were made by Dr. Oggle, in the zoological gardens, in Philadelphia, upon the cubs born of lions in captivity. He found that 90 per cent of the cubs had cleft palate, which was attributed largely to the deficiency of boneforming materials. The defect was found to disappear in the young when the lions were fed, during their gestation, upon the entire carcasses of animals, including, of course, the bones.

Heredity, no doubt, plays an important part in causing cleft palate. Rachitis and the presence of degeneracy in the progenitors are frequent observations. "Maternal impressions," so much believed in by the laity, can scarcely be accepted as a factor in the production of this condition. Mechanical influences, such as the inter-position of parts in the embryonal clefts, anamolies of the ammion, are thought to cause these deformities. Since the development of the superior maxillary bones begin about the twenty-eighth day of intrauterine life; the union of the palatal processes beginning in front, about the eighth week, and is closed at the back part at the eleventh week, so, whatever the causative factor it must occur in the first weeks of fetal life. I shall not enter into a detailed history of the various cleft palate operations, but only wish to call your attention to a method originated by Ziegler, an Australian surgeon some fifty years ago; but it is to Dr. Brophy, of Chicago, that the credit is due for modi

fying and applying of late years this operation. You are all aware that the tendency of the American and European surgeons, nowadays, is to not operate before the second or third year or later. My object in presenting this paper is to suggest that the best time for cleft palate operations is within the first few months after birth.

The reasons for the present general opinion and tendency among surgeons to do a late operation is because the operations that have been practiced upon infants for cleft palate have not been successful, and have been attended by a high rate of mortality. The causes for these results being that infantile tissues are delicate, and the sutures in many cases pulled out; the operations employed necessitated considerable loss of blood, and unnecessary destruction of the parts. In the operation that I will describe, there is a minimum loss of blood and no destruction of tissue; it can be performed in a very short time, and the results, as I shall show from Dr. Brophy's statistics, are amazing to say the least.

The technic is as follows: The child is chloroformed, the mouth and nasal cavity having been previously rendered as aseptics as possible. The operator raises the cheek and passes a heavy braided silk suture (by means of a curved needle with eye in the point) high up on the buccal aspect of the maxillary bones, above the alveolar and just behind the malar proeesses. This suture emerges at a point on the opposite side corresponding to its entrance. (Some difficulty may be encountered in passing the needle entirely through the maxillary bones; when such is the case, two separate sutures can be passed from each side and meeting in the middle a loop is made and one of the sutures drawn entirely through.) A second silk suture is inserted just anterior to the malar process and on the same level with the first suture.

These two sutures are now replaced by moderately heavy unannealed silver wire No. 20, which is doubled if the width of the cleft or the rigidity of the bones seem to require it. There are now two heavy wires passing through the maxillary bones above the palate; one in front and the other behind the malar process. Two perforated lead plates, made from sheet lead (of medium thickness,) which should vary with the extent of ossification of the bones and the width of the cleft), are next cut and moulded to fit the sides of the wound through which emerge the silver wires. The wires are drawn through the perforations in the plates. The two right and the two left protruding ends of the wires are now twisted together over the plates. At this stage, before the wires are twisted the edges of the bony cleft are vivified, so as to admit of a broad osseous union. A forceps made to conform to the shape of the buccal aspect of the jaw

can now be applied in order to bring the bones together; however, the thumb and finger can exert sufficient pressure to do this; the bones are held in apposition by twisting of the wires.

If the bones cannot be approximated, a knife may be introduced. deeply in a horizontal direction, above the lead plates, the bones will be so weakened as to easily be moved towards the median line. This incision should be made on both sides when necessary. When the freshened edges are thus perfectly coapted, the twisted ends of the wires are turned down against the plates and the operation is completed.

In case of a wide continuous cleft, the inter-maxillary bone protrudes forward; it is best restored to its normal position by the removal of a Vshaped piece from just below the vomer, when it can be pressed into place and secured there.

If the patient is an adult or a child over one year, the above operation is not practicable, but instead Warren-Langenbeck's operation with Brophy's modification gives the best results. As you know, this operation consists in loosening of the periosteum and overlying tissues of the palate so that the aperture can be closed by suturing them in the center. The modification made by Brophy in this operation is the use of silver wires and lead plates to relax the tissues instead of the lateral incisions, as usually practiced. There are several advantages in using the modified operation. (1) The troublesome hemorrhage, which frequently follows from cutting the anterior branch of the palatine artery, in making the lateral incision in the hard palate, and the increased chance of infection, are avoided; again the lead plates do away with the necessity of a myotomy, which is generally practiced in the soft palate, the results being that many times the muscles (tenor palati) separate leaving the palate stiff from the connective tissue union which follows, and which very materially affects the functions of the soft palate. In case the soft palate, after suturing is too short to close the naso-pharnyx, it can be lengthened by making a flap from each palato-pharyngeal muscle and uniting them in the median line.

The after-treatment of these cases is much the same whether for a child or an adult. The mouth, nose and pharynx should be kept in as nearly an aseptic state as possible. Only liquid food should be allowed, and after each feeding the mouth should be gently cleansed with an antiseptic lotion. In children great care should be observed in that the hands are not permitted to come in contact with the mouth, and to prevent this, I use a jacket much after the fashion of a straight jacket or camisole; this the child wears until the parts are sufficiently healed that the fingers cannot harm the sutures. The child should be kept as quiet as possible, and vomiting, coughing and crying should be guarded against.

The silver wires and plates are left in situ until perfect and strong union has been established, which usually takes from two to three weeks. If silk sutures have been used they can be removed at the end of a week.

The reason that I chose this subject is because the operation that I describe and recommend in this paper is not generally used, and although employed by Brophy twelve years ago, the operation is described or mentioned in but few, if any, of the modern text-books of surgery. Why this I do not know, as it appears to me to be the operation par excellence, and the only one to be resorted to when the patient is one year or under.

There are many reasons why the cleft should be closed as early as possible, that is a few weeks after birth. As Lawson Tait said, many of these children die from starvation, from inability to take sufficient nourishment. If they survive, there is much likelihood of acquiring such maladies of the respiratory tract, as pharyngitis, laryngitis and bronchitis, which weaken their constitution and may be the starting point of more fatal diseases later. We have in favor of early operation the softness and pliability of the tissues; the bones are but partially ossified, the nervous system of the child is not so highly developed; anesthetics are remarkably well borne by children, the child being young does not realize the condition of things and has no "fear," which often plays an important factor in operations upon older children, and which sometimes occasions the subsequent shock. Another good reason for early operation is that the habit. of speaking through the nasal passages has not been established, which, when once formed is not by any means easily eradicated.

The feelings of the parents must be taken into account, especially of the mother. One can imagine the dire results upon a highly sensitive and nervous woman who must be confronted by her child suffering from such a conspicuous and repulsive deformity. I know personally of a case in which such a child was the exciting cause of insanity, in the mother, and which ended in suicide.

One of the advantages of an early operation is that the depth of the palate is not lessened, while if you wait until later and do the WarrenLangenbeck operation, it lowers the palatal arch a great deal, and may interfere seriously with articulation. In cases of cleft palate the width is increased, and in the majority of cases after the operation advised in this paper the upper and lower jaws are in about normal relation to each other. However, if the width is less than normal, it can be easily remedied by a dental appliance later in life.

With regard to the power of proper enunciation following early operations, that is, before the sixth month, the results are always good. After

the child has begun to talk, great care and persistent efforts of training are often necessary to overcome the defective speech.

Dr. Brophy believes the operation should not be done later than the sixth month. The writer saw Hopkins perform this operation upon a child eleven months old with excellent results. I see no reason why it cannot be done after the sixth month, even as late as the first year.

While my personal experience has been rather limited, having had but four cases, all under four months old, the results obtained were good. But having been in a position to see much of the excellent work done by Dr. Brophy, I am thoroughly convinced that in all cases of cleft palate the earlier the operation is done the better, and this method is the one that will give the most satisfactory results.

One cannot help but marvel at the wonderful results of the operation obtained by Dr. Brophy. In 211 consecutive cases of children under six months old with not a single death, and good results in every case. When we compare the above statistics with those of Wolfe of Berlin, who operated upon 66 children under one year with 14 failures and 7 deaths (over 20 per cent failures and a mortality of 11 per cent) and the 10 cases under two years of age reported by Ehrmann, the results being two deaths and two failures, we are at once impressed with the superiority of this method above all others.

DISCUSSION.

Dr. Henry. I wish to compliment Dr. Condon upon his paper and for bringing before us such an important subject. Much is to be gained by an early operation as seems demonstrated by the four cases reported in the paper.

Dr. Moore.-A very important condition brought out in this paper is the effect of cleft palate upon the mind of the mother. It is always a source of distress and can easily have a permanent effect, especially if the mother should be of an excitable and nervous temperament. In such cases there may be even great danger to her mental condition. Furthermore, nourishment is always greatly interfered with, especially if there be harelip in connection with the cleft palate. In such cases, it is almost impossible for the child to be nursed sufficiently to support life.