On harelip and cleft palate

Before the year 1830, when operative treatment for the closure of cleft palate first attracted attention, and began to be recognised as a legitimate surgical procedure, the only means of alleviating the troublesome symptoms resulting therefrom was by the use of artificial mechanical appliances; and in spite of the increased safety and certainty, the outcome of increased knowledge, with which such operations are now performed, the use of these has not been entirely superseded, and in America they are still much in vogue. These appliances are called obturators or artificial vela according to their position and function in the mouth.

“An obturator is a stopper, plug, or cover, stationary, and fitting to an opening, with a well-defined border or outline, and closing the passage.

“An artificial velum is an elastic moveable valve, under the control of surrounding or adjacent muscles, closing or opening the posterior nares at will, and applicable to cases of congenital cleft, occasionally when the soft palate has been destroyed by ulceration, but never merely to perforations of the hard, or soft palate.”[98] Such are the Utopian definitions given by American dentists.

It may be interesting to pass in review some of the ingenious appliances which have been from time to time suggested, and to indicate some of the various steps in the progress of their production.

It is evident that the ancient Greeks were acquainted with some means of closing or remedying acquired or congenital defects of the palate; but nothing is known definitely of the method adopted. In the year 1565 Petronius, in his work ‘De Margo Gallico,’ proposed to close the opening by wax, cotton, or with a gold plate adapted to the curve of the palate; but in all probability this was no new suggestion. Ambrose Paré, in his book on Surgery, published in Paris in 1579, translated into English in 1649, suggests that the cavity should be covered over by a gold or silver plate, “made like unto a dish in figure, and on the upper side which shall be towards the brain, a little sponge must be fastened, which when it is moistened with the moisture distilling from the brain will become swollen and puffed, so that it will fill the concavity of the palate, that the artificial palate cannot fall down, but stand fast and firm, as if it stood of itself.” A modification of this was suggested shortly after by Isaac Guillemeau, who, to increase the accurate adaptation of the obturator, proposed a “packing” of sponge or lint around the edges of the apparatus. At the beginning of the eighteenth century, Garangeot, in his ‘Treatise on Instruments,’ proposed to fix the sponge, which was placed above the obturator in the nose, by passing through it a screw stem, arising from the upper surface of the plate, and screwing a nut down upon it; evidently trouble had arisen in some cases from the nasal sponge becoming liberated, and retained in the nose.

In this country, Wiseman, Sergeant-Surgeon to King Charles II, suggested the accurate filling of the cleft with a paste composed of myrrh, sandarac, and a number of other ingredients; but as to the means by which this was to be maintained in position we are left in ignorance.

The discontinuance of the nasal sponge seems to have first occurred to Astruc, who, in his ‘Treatise on Syphilis’ (1754), replaces it by a silver button attached to the upper surface of the obturator in order to avoid the unpleasantness arising from the absorption of mucus. This was soon followed by another suggestion emanating from M. Pierre Fouchard (1786), who describes a silver obturator with an arrangement of metallic wings, worked into position after introduction through the opening by means of a hollow stem and nut, which, when screwed down, kept the wings covered with soft sponge across the aperture. The introduction of “elastic gum” as a suitable substance to be used in the restoration of the velum and uvula was the next step in advance; this was utilised in 1820 by M. De la Barre, who devised some very clever, but extremely complicated pieces of mechanism. Thus far it appears that no particular precautions had been taken to secure the accurate fitting of the apparatus; but in 1828 Snell drew attention to the necessity of obtaining an accurate model of the mouth, and his results, in consequence, were much more satisfactory. Since that period various instruments have been devised and used with more or less success; but in this work it is unnecessary to do more than mention the names of Stearns, Kingsley, Sercombe, Ramsay, Oakley Coles, and Wolff as being authorities on the subject, and to indicate some of the plans adopted.

The obturators employed in recent days have been much simplified, and practically have been reduced to a simple plate fixed in the roof of the mouth by an arrangement similar to that employed for ordinary dental plates, i. e. attached to one or more of the teeth. This is a great improvement on the old form of “plug” obturator, which by its constant pressure had the effect of increasing the size of the opening.

Artificial vela are always somewhat complicated, and that success will attend their use cannot be assured. They consist of a vulcanite or gold palate plate fastened to some of the teeth, and of a moveable flap attached to it by a hinge and spring of suitable strength (Figs. 72 and 73), or simply of a rubber flap sewn to the posterior margin of the plate (Fig. 74). These vela either rest above the palatal segments, or their sides can be grooved to allow the palatal segments to fit into them. It is very difficult to obtain an artificial velum sufficiently strong to retain its position, and yet light enough to allow of its being easily moved by the displaced and probably weakened muscles.

In 1864 Dr. N. W. Kingsley, of America, suggested for this purpose the use of soft india rubber of such delicacy as to resemble the normal velum as nearly as possible. The rubber was arranged in two layers, one of which rested above and behind the cleft, and the other overlapped for about half an inch all the margins of the cleft seen from the front. This amount of overlapping was found sufficient to prevent the apparatus from becoming displaced during muscular contraction, and at the same time by its means allowed the palate muscles to effect closure of the posterior nares.

Mr. Baker, in the ‘Boston Medical and Surgical Journal,’[99] describes a velum consisting of rubber distended with water, which was fixed with a hinge to the back of the palatal plate, and under the control of the muscles by being inserted above them on either side. A stop prevents it falling too low, and the posterior extremity is almost semicircular to allow of perfect apposition with the pharyngeal wall, which is drawn forward by the superior constrictor. He claims to have met with much success.

Wolff and Schiltsky have devised a similar apparatus, but use air instead of water for distending the hollow rubber velum.

The main arguments that have been educed in favour of the use of artificial substitutes for the palate rest upon the fact that until recently the results of operative interference in severe cases of fissured palate were often very unsatisfactory; in most, if not all, an aperture was left anteriorly, which caused the speech of the patient to remain indistinct. But with the greater success which has followed increased experience and practice, this cause can be eliminated; and, moreover, secondary operations for the attainment of this object can always be undertaken with every prospect of success. Another objection raised to operation is that no immediate improvement takes place in the power of clear articulation; and although this is perfectly true, the patient is in the same condition in this respect as when first provided with an obturator, and will require the same educational process for the improvement of speech. Again, the mental effect on patients operated on is much more satisfactory than that following the application of artificial assistance; whilst the presence of a foreign body in the mouth is a source of continual danger and irritation; for there is always the possibility of the obturator slipping out of position and becoming impacted in the pharynx or œsophagus. Irritation of the sides of the cleft not uncommonly results from their use, and may end in ulceration and even necrosis. When obturators and vela are removed from the mouth, a spongy granulating surface is often seen, bleeding on the slightest touch, and giving rise to a peculiar fœtor of the breath. Under these circumstances a temporary discontinuance of the apparatus becomes necessary, a most undesirable and unpleasant contingency.

Again these appliances cannot be fitted to a patient much before the age of fifteen, and the habit of defective articulation has been fully formed by that time. They also need constant renewal, and are thus a source of continual expense, putting them beyond the reach of hospital patients.

In spite, therefore, of the optimistic arguments so boldly maintained by our American dental confrères, and of the successes they claim to have attained by the use of these artificial means, I am driven to the conclusion that in the majority of cases of cleft palate operative interference, followed by a suitable educational course, will give results incomparably superior to these, and unattended by the above-mentioned disadvantages.

But whilst strongly maintaining the superiority of the treatment by operative rather than by mechanical means, I will readily grant the greater applicability of the latter in certain conditions; viz. in acquired defects of the palate, the results of syphilis, traumatism, or surgical operations involving extensive loss of tissue—as, for instance, after excision of the superior maxilla: obturators are almost invariably the only means by which these apertures can be closed. In cases of congenital cleft where the os incisivum has needed removal, leaving a broad anterior opening the closure of which by operation is often impossible (p. 135), the application of an obturator is similarly advisable; and one suggests this method of treatment the more readily from the ease with which it can be effected, inasmuch as it merely necessitates an extension backwards of the plate which carries the artificial incisors. The communication between nose and mouth is thus effectually closed, and the functional success of previous plastic work and subsequent educational efforts ensured.

In cases of hopeless deformity, where the palatal tissue is so attenuated that operative interference is impracticable, the recourse to artificial assistance is inevitable; but such cases are fortunately rare.