AT WHAT AGE SHOULD A CLEFT OF THE PALATE BE CLOSED?
BMJ (Clinical Research Edition)
IVERPOOL INFIRMARY 1FOR C1li TDI)EN. OF recenit years there has been a imiarked tendency towvards tile performance of tlhe operationi for closure of the cleft of tile palate at an earlier age tllani formerly. But surgeons whose experience of this operationi reniders tlhemni well qualified to express an opinlioni are by n-o means -gree(l as to tile age at whicll it is most (lesirable to operate. Wh1lile, on the one hand, Mr. Arbuthnot Lane says the b)est age, provided tlle lhealth of tIle child
... alth of tIle child permits of it, is durinig tlle fiftlh week, Mr. James Berry, on tlhe otlher, is strongly of Opiniionl that in the vast majority of cases the age at wllich the operationi is undertakenl with Inost advanitage to tile patient is some time (lurilig the tlhird year of life. During the last fourteenyears I liave performed more than 300 operations for hare-lip, or cleft palate. The ages of the patients varied fromi a week to twenity-onie years. From the experience thus gained I have arrived at the following collelusionis. The usual type of deformity is a complete cleft of the palate associated witlh a hlare-lip, and in the followinig remarks I refer more particularly to this class of case. So far as the palate is concerned the ehief object of the operation is to renider the powers of speech more perfect than they otlherwise could be. Tlierefore, from a purely tlieoretical point of view, the earlier in life the cleft is completely closed the better. From a practical point of view, howQver, tliere are several objections to the complete closure of the cleft (turing infancy. These objections have reference to tlle operation of staphylorrhapliy ratlher tllan to that of uranoplasty. In the case of a child born witlh a complete cleft of the palate, the subsequent powers of articulation, t}lougli ,greatly improved, will never be perfect, even thouglh an operation hlas been successfully performed during inifancy. Tile explanation, I believe, is that wlhen the cleft involves the hard palate, the defect in development is not limited to the structures of the mouth, but also includes the nasal chambers, which are so largely concerned in the production of the voice; conisequently some imperfection in articulationis to be expected in cases in whicil the llard palate lhas been involved, even though an operationi for the closure of the cleft hlas been successfully performed. If, oIn the other llanid, the dlefect is limited to the soft palate, the progniosis is much more hopeful. [ have Ilad several cases in whic'h I operated for a cleft of the soft palate onily before the children could talk, and tllree or four years afterwards they spoke quite naturally, it being impossible to detect from tlheir speeclh that the palate had ever been cleft. As further confirmatioin of the statemenit that the cleft in the palate is niot enitirely responsible for the nasal character of the articulation, one has only to remember that from time to tinlme children are seen who speak as if there were a cleft of the palate, but oin examining the moutlh the only defect noticeable is that the palate is hiiglhly arched, tlhus encroaching upon the nasal chambers. I am quite convinced that in order to obtain tIle best result in respect to articulation, it is essential for the soft palate to be well formed and freely movable. Otherwvise it cannot act satisfactorily as a nasopliaryngeal diaphragm. OPERATION UPON THE HAIRD PALATE. I believe the cleft of the hard palate may with advantage be closed during infancy, not by raising a mucoperiosteal flap from the palate bones on either side and unlitinig them in the lniddle line, for, owing to the width of the gap, this would in most cases be impossible, but by raisinig a muco-periosteal flap from one side, and turning it over on a margin)al hiinge, as suggested by Mr. Lane. If this is decided upon, it certainly shiould be done before operating uponl the lip. A raw surface is tllus left to gran-ulate, but in the hard palate, provided the gap is closed, excess of cicatricial tissue is of no moment. ()OPI:RATION ON TIIE SOFT PALATE. In the case of the soft palate, however, the matter i3 somewhat differenit. In order to obtain a well-formed and freely movable soft palate, excess of cicatricial tissue must be avoided. If tile cleft of the soft palate is closed during infanicy, this can only be donie by means of a turnover flap, whicll of necessity leaves a raw suLrface to granulate, and( wvill ultimately cause some contraction and stiflening of the parts. If, on the other hland, the operation uponi the soft palate is postponed until the ehild is about 2 years of age, there is more tissue to work with, anld it is generally possible to faslhion a goo(l soft palates an(1 uvula by paring the edges of the cleft aind uniiting themii in tlhe middle line. Excess of (icatricial tissues is tlhus obviated, for union takes place by first intention. Tllough I lhave of recenit years operated uponl the hard palate during infanicy and elosed the cleft of the soft palate later, I am niot convinced that the subsequenit powers of articulationi ill these children lhave beenl better than ilL those in wvlhom the complete operationi has been postponed uintil tie seconld or tlhird year. I am conviniced, lhowever, it is uiliwise to operate upon the soft palate durinig infancy, for my best resuilts have been obtainied. whleni the cleft was closed a few years later in life. BizoPiHaYs OPERATION. Professor Broplhy of Chicago lhas drawvn attention to' the fact-wilich I have o*n several occasions verified that in a complete cleft (of the palate the superior maxillary arch is excessive in diameter by just the width of the-(cleft. For some years Dr. Brophy has overcome this defect by forcing the miaxillary and palate bones together in the middle line. The cleft thus obliterated, it onily remains to pare the edges and unite tllem together. I have on two occasions adopted this procedlure, following to the best of my alility the writteni instructioiis of Dr. Broplly. In neither case was I successful in obtaining satisfactory approximationi of the palate bones, and therefore did niot proceed furtlher witll the operation. Thlere is no doubt that in plastic woork especially the skill of the iIndividual surgeon coun1ts for a very great deal, anid it is quite possible tllat miiy defect in iimanual dexterity accounlted for my want of success. Howvever that may b)e, I do niot propose to againi attempt the operationi unitil I am satisfied that the results, as regards speech anI4 appearance, are after this mnethod appreciably better than can be obtained by less severe and less danjgerous measures. After all said ancd done, the object with whichl an operationi for cleft palate is unidertakeni is to render the afflicted inidividual more capable in later years of fighting hiis battle in life. There can be no virtue per se in closing the cleft during infancy; the real test of the operation is. the remote and niot the imimediate result. CONCLUSION. All surgeonis are agr-eed that the (left silould be completely closed during tile first few years of life; buLt thepoint yet to be decidled is wlhether it is better to operate during early inifancy or during early eliildIlood. For my own part, for reason-s I lhave already menitionied, I prefer as a general rule to postpone operatinig upon the palate until the chlild is between 2 anid 3 yeais of age, anid tlhe at one operationi completely close tlhe cleft. The questioni, lhowever, is clearly a matter of evidence,. and well worthly of inivestigationi. In London there is surely plenity of material available and if at one of tIle medical societies a series (If cleft palate cases from four to six year-s after operationi were brouglht forward by surgeonis wlho lold (diverse views-. respectingc, the age at wlicll tile operationi shiould b)e perforimied, in order to denmionstrate thle after-results of their operation-s (a set-piece for recitatiomi, suC'1i as " This is tmeliouse tlhat Jack built,' +would certaillly Ie a niovelty), some liglht woulld be thrown-uponl the vexed questioml, At what age slhould the operationi be performed ? WOMEN AS UJNIVERSITY LECTIURERS.-The Austrian Minister of Public Instruction has recently addmressed a circular to all the universities of the Empim-e inquiring as to their attitude in regard to licensing women as lecturers. So far only the philosophical faculties of the German ancd Czech universities of Prague have replied-the former in an affirmative, the latter in a negative sense. FEB. 3, I906.] I =