CLEFT PALATE (tiranoschisis, pala oschi6is.) Pathological Anatomy and the cleft contin ues through the alveolar process and the superior maxilla (gnat hoschisis, maxillary cleft) and if it further involves the upper boundary of the buccal cavity, it is termed cleft palate (palatoschisis).
The union between the hard palate and the intermaxillary bone, and further between the vomer and the velum on the side, may be par tially or entirely incomplete. Similarly, the parts of the soft palate which develop from the two sides may be prevented from median union and thus participate in the cleft. This may be unilateral or bilateral, according to whether it occurs on one side or both sides of the vomiter.
The fissure may be confined to the soft palate and the uvula, it may extend a varying distance forward through the hard palate (Fig. 15), or in rare cases it may involve the hard palate alone (uranocoloboma). Each form may exist alone or be accompanied by a cleft of the lips, as for instance in fissure of the lips and the soft palate (Fig. 16).
Cleft palate adds a considerable handicap to the living conditions of the child. The acts of sucking and swallowing are impeded, as the milk frequently flows back through the nose. The dangers to the respira tory tract have been referred to when treating of harelip. The speech is considerably disturbed. As it is impossible to close the nose from the buccal cavity, phonation undergoes a considerable pathological change. This refers especially to the confined sounds in which air is pressed against a stenosed or occluded spot at various locations in the buccal and faucial cavities while the buccal cavity is closed from the nasal cavity by the velum drawn up and pressed against Passavant's ridge. If this closure is defective at any one place, the air current will escape toward the nose and is no longer able to accomplish closed phonation or to blow through the phonation stenosis. As a consequence, the con sonants in question (p, t, k, s, f, and eh) cannot be pronounced, or will be pathologically and incompletely replaced in an abnormal manner (Gutmann). Owing to the continuous vibration of the open nasal
cavity the voice has a nasal sound.
The methods of operation. are limited by the principles of incision established by v. Langenbeck. None of the other methods (Lanne longue, Lane) even approaches the simplicity, precision, and safety of the instructions of v. Langenbeck.
I have operated on forty-five cases according to this method and it has with a few modifications proved satisfactory in all. A few of the steps proposed by v. Langenbcck, such as dividing the palatine muscles, as well as chiseling off the hamulus, which was later practised by v. Bill roth, have been proved physiologically deleterious to clear pronunciation.
The preparation for the operation is the same as for harelip. This being attended to, Whitehead's mouth gag is inserted, wit!: depressor attached on its lower side, this mechanism allowing any desired depres sion of the tongue (llelbing).
Here again I employ the drop method of ether anesthesia. The child is amesthetized, the analgesic stage being used for opera tion, while the intermittent stages of awakening are utilized for com pression, arresting hemorrhage and renewing amesthesia. This procedure is incomparably gentler than the deep chloroform anesthesia generally adopted, since this adds another shock to that of operation.
The illustrations will explain the method of incision: An incision is madc to relic VC tension along the dental border not too near the cleft so that the bridge need not be too narrow. Posteriorly the incision may turn around the last tooth and terminate against the check so as to obtain the broadest possible Hap. Then follows detachment of the periosteum from the hard palate and amputation of the fold of the nasal mucous membrane. The resulting cavity is filled with adrenalin cotton plugs, and the other side is treated correspondingly. Now the edges of the fissure are freshened as closely to the margin as possible, always taking care that broad surfaces will result for the union. The knife should be held obliquely.