CONGENITAL MALFORMATIONS The oral cavity, or to be more exact, the bones and integument hav ing a part in the structures of the mouth, are frequently thc seat of congenital malformations in the form of abnormal clefts.
In order to understand the origin of these fissures the adjoining illustrations will be found helpful. Fig. 2 represents the face of an embryo about 4 weeks old. Fig. 3 is a diagrammatic representation of the most common congenital malformations. A comparison of the two figures will show the origin of some congenital fissures. It is obvious that the mesial fissure of the upper lip is produced by a failure in the fusion of the globular processes. The transverse cleft is a consequence of failure in the obliteration of the fissure between the maNO.11ary and the mandib ular processes. The lateral fissure of the upper lip, or harelip, indicates that the cleft between the globular and inaxillary processes has failed to close; that is, the single lower and small inner limb of the Y-shaped cleft system illustrated in Fig. 2. The oblique facial fissure arises from the cleft which extends between lateral nasal process and the maxillary process in the. direction of the orbit; that is, the lower single and the external larger limb of the Y-shaped cleft. system.
Harelip (labium leporinum) in its various grades is the most frequent of the congenital mal formations. The simplest grade occurs as a depression in the upper lip near the philtrum, which in the form of a glistening streak occasionally extends to the nostril (partial harelip). A6 a rule the fisstire extends to the nostril (partial harelip, second degree), or is prolonged into the nose, so that its upper end is not visible (total harelip). Often the harelip occurs on both sides and very often it is combined with a malformation of the ntaxilla.
The prognosis of harelip depends primarily on the extent of the malformation and the strength of the affected infant, As the alimenta tion is often hindered and the exposed minions membrane is subjected to inflammatory processes of various kinds, the question of operative intervention must be considered very early (second to fourth week).
A more unfavorable prognosis is submitted by those Nimbi] clefts which are combined with malformation of the palate. The most common combination is that known under the name of wolf's throat (see Fig. 4).
The wolf's throat consists in a cleft of the hard palate, which is divided by the vomer into two fissures. This cleft may extend posteri orly in the median line through the soft palate and anteriorly terminate in a double harelip, between which the free intermaxillary bone pro trudes. This malformation represents the extreme grade of cleft palate. Defects or fissures of the palate are frequently observed and give the voice a peculiar nasal twang. These must be attributed to a palatal cleft which has partially healed during intra-utetine life.
The serious derangements which result from congenital defects of the palate embrace, above all, the functional disorder of the act of nursing and deglutition. Although the milk may be placed on the dorsum of the tongue by means of a spoon or dropper to stimulate the act of swallowing, a large portion of the food, fed with difficulty, flows outward again, and it is necessary to resort to gavage in order to save the infant from starvation.
The danger of an inflammatory process attacking the mucous membrane is greater in these cases than in harelip, since the nose, and mouth communicate freely. Even before an operation can be under taken, these unfortunate infants usually succumb to an intercurrent affection, such as a bronchopneumonia, or a digestive disorder induced by swallowing food particles which have undergone putrefaction in the nose.
The cause of this malformation must be sought in some hindrance to proper development, mostly some mechanical cause; as an abnormal embryonic displacement of the base of the skull, an abnormally developed amnion or an increased intra-cranial pressure. A primary atrophy of the borders, a possible result of an inflammatory process which pre vents fusion, has also been designated as a possible cause. Hereffity plays a most important role in these as in all congenital deformities.