On harelip and cleft palate

The period of life at which an operation can be safely undertaken for Cleft Palate is a matter which demands careful consideration. Before the introduction of anæsthesia the assent of the patient was required, and therefore the operation was seldom performed before the age of puberty. With the aid of chloroform this is obviated, and we can now operate at an earlier period; undoubtedly as regards the subsequent power of articulation the earlier the operation is performed the better. On the other hand, the palatal tissue in infant life is so delicate, and the cavity of the mouth so small that a plastic operation is attended with more than usual difficulty. Further it is almost impossible to keep an infant sufficiently quiet to allow of primary union, as it is constantly interfering with the stitches by pushing the tongue against the wound, and sucking the edges apart. Statistics of results, moreover, tend to prove that such operations conducted on young infants are not only directly dangerous to life, but also indirectly, by depressing the general vitality and increasing the liability to subsequent disease. Thus Ehrmann[86] records ten cases operated on under two years of age with two deaths, two failures, and six cures, which latter he considers due to the fact that the children were fed after the operation by œsophageal tubes passed through a protective plate of hardened rubber so as to prevent interference with the sutures. Of these six cases cured, only one was living after four years had elapsed, and in this the soft palate only had been closed. He considers that the loss of blood, and the shock of the prolonged operation or operations interfered in a serious manner with the vitality of the patients. These are, perhaps, somewhat scanty facts to argue from, but they tend to show that there is a greater risk associated with operations performed at an early period of life, although we have the authority of many well known surgeons for attempting them. Thus Billroth has operated at the age of four weeks, Roye of Lausanne at eight days; but my own experience is certainly in favour of deferring operation until the child is at least three years old, or as soon after that period as possible if it is at all of a tractable disposition; the moral control at this age is usually sufficient for our purpose.

As to whether the whole cleft should be dealt with at one operation or not, the practice of surgeons differs considerably; and indeed each case needs to be decided upon its own merits. Where the cleft merely involves the soft palate, or possibly extends but for a short distance into the hard, one operation will usually suffice; but in extreme cases of complete cleft of the hard and soft palate with wide separation of the edges, it may be advisable to deal at different times with the hard and soft, some preferring to close the hard at the first operation, and others the soft. This must depend upon the surgeon’s confidence in himself and in his patient. Personally I always prefer, if practicable, to obtain union in the hard palate at the first operation; then if after taking the necessary steps for loosening the muco-periosteal flaps the parts appear to come easily together, the edges of the whole cleft can be pared, and the whole process completed at one sitting. I cannot too strongly insist on the paramount importance of obtaining firm union in the anterior part of the palate, for if the smallest opening be left in that situation, distinctness of speech in after-life will be seriously impaired.

Preparation of Patient.

The state of the health and the local conditions of the mouth, nose, and pharynx must be carefully examined before the operation is decided on.

The little patient’s general condition must be as satisfactory as possible, and a course of tonic preparatory treatment (including possibly a change to the seaside) is often advisable. Sources of infection from measles, &c., should be carefully avoided, and for a few days prior to the operation they should be kept under observation and at rest, to prevent any likelihood of catarrhal developments.

The local conditions, too, must be satisfactory. There should be no excessive secretion from the naso-pharyngeal mucous membrane, as such is usually associated with an œdematous infiltration of that structure, most unfavourable to the attainment of primary union; and, moreover, this excess of mucus tends to insinuate itself between the edges of the flaps. If present, it should be treated by rest in a warm mean temperature, bland diet, and the application locally of gargles of boracic acid and chlorate of potash, combined with the careful use of astringents such as tannic acid and alum; the tongue also should be clean. The state of the tonsils should be looked to, and when greatly enlarged they ought to be previously removed, for they may materially interfere with the union of the palate, either from their size, or from the possible supervention of inflammation; when only moderately enlarged there is, I believe, no necessity for their removal; on the contrary they subsequently assist in closing the aperture between the nose and mouth during speech. Similarly post-nasal adenoid growths should not be interfered with, unless absolutely necessary (p. 70).

For the immediate preparation of the patient it is advisable that the bowels should be moved the day before operation, that no food be administered for at least six hours previously, and fluids only for some hours prior to this.

The patient should be placed on a suitable narrow table in such a position that the light falls well into the mouth. Where practicable, a graduated head piece capable of being raised and lowered, in order at one time to throw the light on the soft, and at another on the hard palate, is desirable; but in private houses this is usually attained by a due adjustment of pillows. To prevent any sudden movement on the part of the patient the hands should be fixed to the side, and my usual method of accomplishing this is to pass a leather strap around the thighs immediately below the trochanters, and to this the wrists are attached by means of leather bracelets locking on to the circular strap by spring hooks. This plan of fixing the arms enables the patient to be turned from side to side to allow blood to pass out of the mouth when respiration becomes embarrassed by an accumulation in the pharynx. If the patient is strapped down to the table, this cannot be accomplished, and the plan just indicated will be found of great practical value. For it must not be forgotten that the anæsthesia is not always so deep as to prevent sudden reflex movements of the hands, which might jerk the operator’s knife and cause serious mischief.

To obviate the dangers arising from the flow of blood into the pharynx and larynx, it has been recommended by Prof. E. Rose of Berlin to operate with the head hanging over the end of the table, thereby causing the blood to gravitate into the nose. I have only adopted this suggestion in one or two instances, but in those in which it was tried considerable congestion of the vessels of the head was produced, and the administration of the anæsthetic interfered with. A skilled assistant should to my mind render such inversion unnecessary.

Anæsthesia.[87]

The importance of efficient anæsthesia during this operation is so obvious that a few suggestions as to the best means of obtaining and maintaining it will not be out of place. First, as to the choice of an anæsthetic, the conditions of the operation are such that chloroform seems the only agent which is conveniently applicable; our patients moreover are generally children, and with such at any rate it may be safely used. It has been recommended and practised by some to produce initial unconsciousness by the administration of the A. C. E. mixture, ether, or nitrous oxide gas, and then to maintain it with chloroform. This plan is quicker, and supposed to be safer, but on either plea the gain, if any, is so slight as to render the extra complication undesirable.

As to the method of administering chloroform, the old plan of soaking a piece of lint or towel with the drug and applying it closely to the air passages until anæsthesia is produced ought by no means to be followed in these days of advanced knowledge. It is well known that more than 4 per cent. of the vapour of the drug is dangerous, and hence a safer method must be employed. All plans requiring the introduction of nasal or buccal tubes are undesirable. The best method is that recommended and always followed in the practice of my colleague, Sir Joseph Lister. The corner of a well-starched towel fixed into a hollow oval by a safety pin, sufficiently long to extend from the glabella to the point of the chin, is kept continually moist by chloroform from a drop-bottle.

It is held close to the face without actually touching it; and when complete anæsthesia has been induced can be held out of the way of the operator, and yet sufficiently near for the patient to be still affected by the drug. Any opportunity of inserting this adaptable mask into the region of the mouth must be always taken advantage of by the anæsthetist, so that as little delay and inconvenience as possible may be experienced.

During the operation a strict watch must be maintained upon the respiratory functions, so that any laryngeal obstruction may be readily noticed and treated. The colour of the pinna of the ear, the mobility of the tongue, if unrestrained by a gag, and the condition of the conjunctival and pupillary reflexes assist in giving useful indications for an increased or decreased administration when the patient’s face is obscured by hands, instruments, or congealed blood.

When the conjunctival reflex is absent, and the pupil dilated and unaffected by light, the anæsthetic should be temporarily suspended.

When the conjunctival reflex is absent, the pupil contracted, and the colour good, the patient is in the best condition of anæsthesia, and this state should be maintained, if possible, throughout.

When the conjunctival reflex is present together with dilatation of the pupil, movements of the tongue, and other “reflex” efforts, the amount of chloroform should be increased.

During the first stage of the operation, when hæmorrhage is profuse, deep anæsthesia is undesirable for fear of blood passing into the larynx. To prevent this, after the incisions have been made, sponge pressure should be applied, and the head turned on one side. Any gurgling in the throat, or dusky colour of the face, indicating threatening laryngeal obstruction by blood-clot, needs an efficient application of a sponge on forceps behind the tongue, the effect of this being not only to remove blood, but also to stimulate closure of the glottis. The bleeding having been arrested, and the later stages of the operation reached, a deeper anæsthesia is necessary. Sudden increase or decrease of the amount of the anæsthetic will readily induce vomiting, and if much blood has been swallowed in the earlier stages, this contretemps may be inevitable in spite of all precautions.

Duties of the Assistant.

For the efficient performance of the various steps of the operation a skilled assistant is absolutely essential. His duties will consist, first and foremost, in keeping the pharynx clear of blood; secondly, in such dextrous use of sponges as will allow the parts to be clearly seen by the operator; thirdly, in the judicious use of a tongue depressor, when necessary; and fourthly, in exercising a careful supervision over the stitches before they are finally fastened.

For the purpose of clearing the pharynx, he must be provided with a pair of long smooth-nosed forceps (Fig. 61 B), and some small loose pieces of purified sponge; or the sponges may be fastened on pieces of stick about six inches long in such a manner and so securely that the necessary manipulations shall not detach them. The former of these methods is, I think, preferable.

The great art in clearing the pharynx consists in letting the sponge slide over the dorsum of the tongue, and then by a rotary movement of the wrist the clots are entangled upon its surface and easily removed. In this manipulation the sponge should not touch the palatal structures more than is absolutely necessary, as any friction or bruising of the edges when pared is highly injurious. Vomiting, moreover, is readily excited by too frequent sponging, especially about the uvula and soft palate.

Instruments.

An efficient gag is one of the most important requisites for a rapid and successful performance of this operation. In the selection of such appliances the choice will lie between those which merely separate the jaws and those which, in addition, command the tongue. The latter are represented by such as T. Smith’s (Fig. 57) or Whitehead’s gags; but with either the tongue is apt to curl up at the back of the plate which is intended to repress it, and severely embarrass, if not altogether interfere with respiration, necessitating a hurried readjustment. Any gag with a tongue plate is not only more difficult to adjust, but also to remove in an emergency. I am inclined on the whole to think that it is better to leave the tongue free, the assistant depressing it, when necessary, with an ordinary spatula. The apparatus should be as simple as possible, unilateral, and easily moved from one side of the mouth to the other, and constructed with a minimum amount of metal and projections which might obscure the field of operation, or cause delay by entanglement of the stitches. These conditions are, I believe, fulfilled as nearly as possible in my own adaptation of the late Mr. Francis Mason’s gag, generally used by Sir Wm. Fergusson (Figs. 58 and 59). As will be seen from the drawing, the gag is unilateral, provided with a sliding ring-catch easily thrown in and out of position, and so made that by reversing ends it can be used either for an adult or a child. The portions inserted between the teeth are covered with rubber tubing or fine twine, thus protecting them from injury, and in some measure preventing the gag from slipping. I admit that the supervision of an assistant is needed to maintain its position, but contend that this is rather an advantage than otherwise, and the breathing is less likely to be interfered with. It is inserted closed between the lateral incisors, and is gently pushed back until between the molar teeth, when it is opened to a sufficient extent, and fixed in that position by the sliding catch.

A small scalpel, raspatories of various shapes, right and left-handed (Fig. 60), long smooth-nosed, and fine hooked forceps, and a long-handled, narrow-bladed, very sharp paring-knife (Fig. 61) are necessary. For seizing the edge of the cleft in order to remove the mucous membrane therefrom, the surgeon will find the forceps depicted in Fig. 62 extremely useful; they are an adaptation of a pair of German trachelorraphy forceps, and possess the following advantages: first, by their angular prehension they can seize the exact edge of the palate, and then when seized, the hold is maintained by means of a spring catch in the handle. It is obvious that a pair of straight hooked forceps (Fig. 61 A) introduced into the mouth cannot so certainly seize the edge, whilst the slightest relaxation of the fingers causes it to loose its hold.

The needles best adapted for this work deserve a somewhat detailed description, inasmuch as the clumsy forms generally in use twenty years ago have been superseded by much more satisfactory and delicate instruments, which inflict less injury in passing through the palatal structures. Those most commonly employed are a special modification of the Hagedorn type of needle (Fig. 63), long, narrow, measuring with the handles about eight inches, fine, curved, and flattened laterally, with a small eye near the point, and so ground and set that there is only a short cutting edge on the convex side close to the extremity. The advantage of this is that when introduced quite close to the edge of the palate, its blunt concave border directed towards it has no tendency to cut its way out, whilst the convex cutting edge makes a track for the needle and suture to follow. It is manifest that the incision thus made is at right angles to the margin of the cleft, and consequently when the suture is drawn tight, the tendency is rather to close than to open the needle track. With the old needles making as they did in their passage an incision parallel with the edge of the cleft, the tightening of the suture caused the opening to gape, and this occasionally resulted in the establishment of a fistulous aperture leading to subsequent trouble. (Compare Figs. 64 and 65.) Mr. T. Smith emphasised this point as far back as 1868. (Vide an interesting paper of his in ‘Med.-Chir. Trans.,’ vol. 51.)

With reference to the sutures, many different materials have been employed, such as silk, silkworm gut, catgut, horsehair, and fine silver wire. For many reasons the silver wire is to be preferred; it can be more easily and accurately adjusted to the required degree of tension, and has no tendency to slip; catgut and horsehair are often so springy that the knots are liable to come unfastened. Silver wire is less irritating, and therefore can be left for an almost indefinite period in situ; it is incapable of absorbing septic material, and is insoluble in the tissues. The method of introducing the wire stitches is described later (p. 119); the wire twister (Fig. 66) will be found useful for the purpose of regulating their tension.

The thickness of the wire used must vary directly with the delicacy or otherwise of the palatal tissues; the thinner the palate, the finer the wire, and vice versâ. In different portions of the same palate, wires of varying thicknesses have often to be used. The principal varieties that I make use of are Nos. 30 and 32 on the ordinary wire gauge. Whichever is used, it should be uniformly and well annealed, otherwise it is liable to break whilst being twisted, and does not straighten out on removal. In the region of the uvula it is better to employ some softer material, such as fine silk or catgut, as the projection of the ends of the wire has a tendency to irritate the back of the tongue and cause coughing and nausea.

A narrow straight probe-pointed bistoury may be needed to extend the lateral incisions into the soft palate, in order to relieve lateral tension.

The Operation.

It will be convenient first to describe in detail the technique of the operation in a typical case of combined cleft of the hard and soft palate, i. e. the operations of uranoplasty and staphyloraphy combined, and subsequently indicate the modifications necessary under special circumstances.

The method which is now almost universally employed is that known as Langenbeck’s, effecting complete closure by dissection of muco-periosteal flaps obtained from either side of the cleft, and sutured in the middle line. Although called after the great German surgeon, and rightly so, inasmuch as he first clearly enunciated the principles underlying the operation, it is certain that similar plans had been previously employed by others. The late Mr. Avery, of Charing Cross Hospital, seems to have been the first in this country to completely close a cleft in the hard palate, and he employed and described[88] a method very similar to Langenbeck’s. This was undertaken in 1848, and in 1853 Messrs. Weiss made improved and special raspatories for the operation. Langenbeck’s paper, on the other hand, did not appear until 1862. Previous to this various plans of surgical treatment had been employed. Operations upon the soft palate were undertaken much earlier than upon the hard, and although priority has been claimed both for Prof. Graefe[89] (1816) and M. Roux[90] (1819), who performed staphyloraphy independently, yet it is certain that a similar proceeding had been adopted by others in the latter half of last century. The first reference to a successful case that we possess is in 1760, when a dentist named Lemonnier[91] united the borders of a cleft in a child. Desault and others record similar cases in the first decade of this century. As regards the hard palate, M. Krimer[92] seems to be the first who attempted operative treatment (1824); he dissected up small muco-periosteal flaps on either side of the cleft, reversed them from without inwards, and united them in the middle line by sutures. M. Beaufils made use of a single flap twisted on itself so as to fill the aperture. Dr. Mason Warren in 1843 published a method of operating which seems in his hands to have been moderately successful, although only after repeated operations. He dissected up the mucous membrane, and freed the soft palate by dividing the posterior pillars with strong curved scissors, and then sutured in the median line. Several methods of “bony suture” have also at different times been suggested. Dieffenbach[93] led the way in 1826, and was followed by many other surgeons, Fergusson and Mason being prominent amongst them in this country. But the results were never satisfactory, and the method has now been entirely superseded by Langenbeck’s operation, which is applicable in almost all cases.

It may be divided into four stages:—

Stage 1. Incision, and detachment of muco-periosteal flaps.

Stage 2. Paring the edges of the cleft.

Stage 3. Passage and tightening of sutures.

Stage 4. Relief of lateral tension.

Stage I.—Incision and Detachment of Muco-periosteal Flaps.

The patient being thoroughly anæsthetised, and the mouth held open by the gag, the surgeon, standing on the right side of the patient, commences by making a lateral incision, preferably on that side of the cleft which is opposite to the gag; it facilitates matters to shift the gag to the opposite side of the mouth when the second incision is made. These incisions should commence a little internal and opposite to the last molar tooth (Fig. 67 A), and should be carried forward parallel to the alveolar margin to a point immediately behind the lateral incisor, terminating a little anterior to the apex of the cleft, if the alveolus be intact. The knife should be held so that the incision is always perpendicular to the varying planes of the mucous membrane, in order to prevent the edge from being bevelled, which may seriously impair its nutrition. All the structures should be cleanly divided down to the bone.

Hæmorrhage, even to a considerable amount, naturally follows, and this should be checked by pressure with purified sponges; it will be much more serious should the palatine arteries be included in the line of incision. The distribution of the anterior and posterior palatine arteries is so variable, and their pulsation so rarely to be felt beforehand, that it is not always possible to avoid wounding one or other of them. Should this occur, it is important that the vessel be completely divided, as a buttonhole in it will cause severe and protracted hæmorrhage. During the bleeding the patient’s head should be turned on one side and lowered, so as to allow the blood to run freely out of the mouth and not into the throat.

Whilst the assistant is staunching the hæmorrhage, the operator can introduce the raspatories through the openings thus made, and working them from without inwards, separate the whole of the muco-periosteal tissue. To effect this, different shapes of instruments will be required in order to follow the curves of the palatal segments, and those devised by Mr. Durham will be found most useful (Fig. 60). In loosening the flaps anteriorly, the advantage of the double-curved raspatory (Fig. 68) will be obvious. As the point of the raspatory reaches the inner free margin of the palatal segment, the separation of the muco-periosteal flap should be completed by the protrusion of the instrument into the cleft at the junction of the buccal and nasal mucous membranes. This is more readily accomplished if the edges have been previously pared; but it is better to postpone this step until the flaps have been detached, as the raw edges are less liable to be bruised by the sponging, and with the flaps loosened the margin can be pared with greater accuracy. In cases where the vomer is attached to one free edge of the palate (Fig. 11) the junction of the nasal and buccal mucous membrane should be incised to prevent its being lacerated by the raspatory.

The attachment of the soft structures to the hamular process and back of the hard palate must be freely and fully divided. This is a most important and delicate part of the operation, and as the structures are here extremely thin, great care must be exercised. Should this separation be incomplete, the lateral incision cannot be carried down into the soft palate, and the flaps will not come into proper apposition. It may be attained by the use of a sharp cutting raspatory kept close to the bone, and as regards the hamular process, by a narrow probe-pointed bistoury, or a pair of curved scissors. The introduction of the left forefinger into the incision is of great assistance in effecting this with precision and thoroughness.

After detachment the muco-periosteal flaps will often appear blanched or of a bluish-white colour as a result of the interference with the circulation, a fact which has been commented on by M. Trélat. The circulation, however, is soon re-established, and the normal colour returns in a few hours.

When this proceeding has been satisfactorily accomplished on both sides, a temporary delay generally occurs for the assistant to arrest the hæmorrhage, and for the anæsthetist to get the patient more fully under control, so that the second most important stage may be conducted without any struggling.

Stage II.—Paring the Edges of the Cleft.

The extreme inner edge of the cleft velum should be seized near the base of the half uvula with the catch forceps (Fig. 62). The narrow-bladed knife (Fig. 61C) is entered with the back towards the tongue, just in front of the forceps, and made to cut the merest shaving from the margin as far as the apex of the cleft. Before relaxing the grasp of the forceps, the same process is continued backwards to the apex of the half uvula. The other side of the cleft is similarly treated, and, if possible, the strip of marginal tissue removed should be continuous throughout, thus satisfactorily proving that the whole of the cleft has been pared. This strip should be cut square with the palate, for if bevelled, the edges cannot afterwards be brought into such accurate apposition.

Care should be taken in this proceeding not to contravene the important canon of plastic surgery, that no unnecessary amount of tissue should be removed; for it is most important to remember that in these cases, there is no excess of material, and that a too free removal of marginal tissue will lead to increased tension in the united palate, and subsequently to a less satisfactory functional result from defective closure of the posterior nares.

Stage III.—Passage and Tightening of Sutures.

The quickest method and the one calculated to disturb the parts the least is a modification of that introduced and practised by the late Sir William Fergusson, the so-called “loop-method.” It consists in the passage of a loop of fine silk through both sides of the cleft, to act as a carrier for the silver wire which is to be the permanent suture. One of the needles already described, previously threaded with a piece of fine silk about sixteen inches in length, so that its ends are equal, is passed from the buccal aspect through the loose flap close to the margin of the cleft (i. e. about 2 or 3 mm. from it), and as near as possible to its anterior extremity. To accomplish this it is unnecessary to hold the flap with forceps, as its margin may be seriously damaged. The needle track should be perpendicular to the palate surface, and therefore parallel to the pared margin of the cleft. The silk is then seized close to the eye of the needle with the smooth-nosed forceps introduced within the cleft, the needle withdrawn, and the loop pulled forwards sufficiently to be laid temporarily on the side of the cheek. The same process is repeated at an exactly corresponding point on the opposite side, so that now there are two loops emerging from behind forwards through the cleft. By loosely threading the right loop through the left and gently withdrawing the latter, the former is carried through the flap on the left side (Fig. 69); in this way we have a double thread, with its loop on the left side and its free ends on the right, passing through the flaps on either side. This process is repeated at intervals of about 5 to 6 mm. throughout the length of the cleft from before backwards, until the uvula is reached, the anæsthetist and assistant guarding the loops and ends of the silk by placing their hands on them at the sides of the face. This is especially needed if much sponging is called for, or if vomiting occur. The uvula need not be dealt with until the silver sutures have been tightened.

The silver wire must next be substituted for these loops, and this is effected by taking a six-inch length of the former and doubling half an inch of one end into a hook over the loop; gentle traction on the free ends of the silk will easily draw the wire through into its place. A small piece of sponge lightly dabbed on the edges of the cleft at the point of suture removes any adherent blood-clot or mucus. The ends of the wire are crossed and the wire-twister (Fig. 66) applied, and in this way the suture is tightened until the margins of the cleft lie accurately in apposition, without undue mutual pressure or folding in of the edges; experience and practice can alone decide the requisite amount of tension. When this has been accomplished, the twisted ends are cut off with scissors, leaving a sufficient length visible to allow of easy removal when necessary. It is better to deal in this way with each wire separately, in order to prevent entanglement or confusion.

To stitch the uvula, a double-curved semicircular needle (Fig. 63) may be advantageously employed, and passed through both sides before withdrawing it; as previously stated, no substitution of wire is advisable (p. 114), but the silk is drawn tight by means of a slip-knot made fast in the usual way (Fig. 70). Two of these silk sutures may often with advantage be inserted in the uvula, but this should be accomplished with the greatest possible delicacy of manipulation, as any rough handling with the forceps may result in bruising, œdema, and subsequent non-union. The sutures, moreover, must be so placed that the circulation in the uvula is not interfered with when they are drawn tight, or strangulation and sloughing may follow.

Although the above detailed process appears very elaborate, it certainly seems to me the best. Other methods are used by many, and amongst these perhaps the most frequently employed is the “direct” method of Mr. T. Smith. In this the needle (Fig. 71) is double-curved and hollow, and the wire which is wound on a drum in the handle of the instrument can be projected at will from the aperture at the point by a movement of the thumb. Different shapes are used for different parts of the palate. The needle is passed from below upwards through one side of the cleft, and without withdrawing it through the other from above downwards; the wire is now protruded from the point of the needle, grasped by forceps, paid out from the drum, and the needle withdrawn as it entered. Mr. Smith’s usual practice is to stitch from the uvula upwards, tying each stitch as it is inserted, and making use of the ends of one stitch to steady the palate whilst introducing the next. The advantage claimed for this method, viz. the saving of time, is more than counterbalanced in my opinion by the following drawbacks; first, the strain exercised upon one of the palatal flaps in order to pass the needle through the other; second, the occasional and not infrequent hindrances to the smooth working of the wire by its kinking; and, thirdly, the difficulty often experienced in seizing the end of the wire.

Stage IV.—Relief of Lateral Tension.

The palate having been thus satisfactorily sutured, the relief of lateral tension and the division of the levator palati have now to be undertaken; for however well the parts may appear to lie, it is never safe to omit this. A narrow-bladed probe-pointed bistoury is introduced through the lateral aperture on either side, and carried directly backwards through the soft palate. It is useful to introduce the left index finger into the lateral opening to ascertain if any fibres of the muscle still remain undivided. This plan was first introduced and practised by Mr. Pollock in mild cases of cleft palate, where the fissure extended through the velum only.

It may not be out of place to notice the method adopted by Sir W. Fergusson for dividing the levator. A triangular-bladed knife set at right angles to a long stem was introduced behind the velum, and the two edges of the angular point made to cut their way between the pterygoid plates down to the bone, so as to divide the muscle close to its origin. From a theoretical point of view this appears all that can be desired; but practically the results following this procedure were not always satisfactory, inasmuch as the tension upon the stitches often appeared to be but little relieved, and one could never tell with certainty whether the muscles were effectually divided or not; in addition to which, unless the surgeon were very skilled in the use of the instrument and the anatomy of the region in which he was cutting, serious mischief might and did sometimes ensue. A knife such as the one to be employed, cutting at right angles to the handle, can never be used with absolute precision, particularly when the part to be dealt with is out of sight. The ease and certainty with which the structures can be divided by the former method of prolonging the lateral incision backwards have rendered this plan of Fergusson’s obsolete, although in his hands it was often very successful.

Should the hæmorrhage from these final incisions made in the soft palate be excessive, steps should be taken to ascertain whether the trunk or any large branch of the posterior palatine artery has been partially divided, as if so the bleeding is liable to recur at intervals, and may become serious. Under such circumstances, complete division of the vessel has almost always the immediate effect of staying the hæmorrhage. Sponge pressure and syringing with iced boracic lotion may be useful adjuncts in arresting the general oozing; but long continuance of the latter is detrimental to the vitality of the flaps and may endanger primary union. For a similar reason, plugging the lateral apertures, or recourse to powerful styptics, such as perchloride of iron, should if possible be scrupulously avoided.

All lateral tension being now relieved, and no serious hæmorrhage continuing, the sutured palate should present a solid, if somewhat blanched appearance in the middle line; the gag can be removed and the operation is complete.

Thus far we have been describing the operative treatment in the severer forms of cleft, in which both hard and soft palate are involved. When, however, the velum alone is cleft, merely the operation of staphyloraphy is required. In such cases the lateral incisions need not be of such an extensive character, and are usually made after the edges have been pared, and the stitches passed. It was for this type of case that Mr. Pollock introduced his method of dividing the levator palati by entering the knife through the mucous membrane of the velum a little in front and to the inner side of the hamular process, which can be felt in the mouth just behind the last molar tooth. The knife is pushed through the substance of the palate, and then by raising the handle and depressing the blade the muscle can be fully divided without making too extensive an incision in front. I should strongly recommend, however, a sufficient incision being made to admit the tip of the index finger, in order to ascertain with certainty that no tense fibres of the muscle remain undivided.

When the uvula alone is cleft no lateral incisions are necessary.

When the cleft extends for a short distance into the hard palate, lateral incisions must be made in the first stage of the operation, extending to a point a little anterior to the apex of the cleft, for the purpose of introducing raspatories to loosen the soft tissues around this point.

In some cases, after the soft palate has been brought together, a certain amount of tension is observed to be exercised upon the flaps by the traction of the muscles in the pillars of the fauces. If this be so, they should be divided by snipping them across with a pair of blunt-pointed scissors curved on the flat. By this means lateral tension is diminished, and the velum can be subsequently more easily approximated to the posterior pharyngeal wall.

Management of the Patient after Operation.

The patient should be placed in bed with the head low and no pillow, so that any oozing or accumulation of mucus, whether from the upper or lower surface, may gravitate into the pharynx; otherwise it may insinuate itself between, and tend to separate the lips of the wound.

A certain amount of shock is frequently observed during this period, and the circulation in the extremities should be promoted by warmth. A shivering fit, scarcely amounting to a rigor, is often observed, but is of no prognostic importance. During reaction, the blood which has been swallowed during the operation is usually vomited; when this occurs early the danger to the palate is not very great; but any vomiting at a later period has a serious disturbing effect, and the greatest care must be exercised in the supervision of the diet and general hygienic surroundings in order to prevent such accidents.

Diet.—It is best to give no nourishment for the first three or four hours, and but very sparingly for the first twenty-four. Iced milk and water, or milk and soda-water, given in small spoonfuls, should be the first food supplied; but after twenty four hours, when the tendency to vomiting has disappeared, the food should be slightly warm. Milk and water given by spoon or from a feeder at frequent intervals will form the staple article of diet; but if the patient be rather older, strong broths and clear soup may be added. By the fifth day they may often safely take soaked bread, custard pudding or some soft farinaceous food; but no hard substance, liable to damage the newly-formed adhesions, should be allowed for fully a fortnight.

If the patient be sufficiently intelligent, it is advisable that the mouth should be gently washed out, especially after food, with a tepid weak boracic solution. This is best effected by using it as an ordinary gargle; syringing the mouth I consider to be unadvisable, because the jet if forcible will tend to find its way between the margins of the wound, and hinder union. Some surgeons recommend that prior to fastening the stitches during the operation, the edges of the wound should be touched with a solution of chloride of zinc in order to assist in keeping them aseptic; this is really unnecessary if careful washing of the mouth after the operation be enjoined.

Of course absolute quiet is essential, and all attempts at talking must be strictly forbidden. The child should be closely watched, and any attempt to meddle with the palate should be prevented by tying down the hands, which may be done as a matter of precaution throughout the whole duration of the case with young children, and as a routine during sleep with all patients. If the child is noticed to suck at the palate, or curl the tongue up against it, an effort should be made to divert its attention.

The palate should not be examined too often. The blanched appearance observed at the close of the operation generally disappears during the first few hours, and a moderately injected condition of the mucous membrane with slight swelling of the palatal tissues is a sign that all is doing well. The lateral incisions usually fill with granulations rapidly, and these subsequently cicatrise; the rate of their healing depends on the width of the aperture and on the vitality of the patient.

It is impossible to lay down any hard and fast rule as to the period when the stitches should be removed. In the majority of cases where the course has been satisfactory the stitches in the velum may be safely removed on the sixth or seventh day; those in the hard palate, if causing no irritation, had better remain a little longer. If there is any doubt as to the firmness of the union, the sutures should not be touched till later, as they seldom of themselves give rise to any trouble. It occasionally happens that a child refuses to open its mouth, and renders removal of the stitches without the chance of damaging the palate impossible; an anæsthetic must then be administered.

After-Complications.

In spite of every precaution taken both at the time of the operation and subsequently, it occasionally happens that the process of repair does not proceed satisfactorily.

This is mainly due either to a low state of vitality on the part of the patient, or to the development of some febrile or catarrhal condition, or to a septic contamination of the wound. Cases have occurred in which diphtheria, measles, or scarlet fever have shown themselves a few days after the operation, and, under such circumstances, there is a great probability of complete failure of union, the stitches ulcerating through, and even a portion of the soft palate being destroyed by a necrotic process. Such a result, however, does not necessarily ensue, for in one of my cases good union was obtained throughout the greater part of the palate in spite of an attack of measles.

In the majority of instances where defective union occurs there has been some neglect in the observance of the precautions upon which stress has been laid above. The most common errors are as follow:

a. Inefficient relief of lateral tension. Of late years I have become more than ever convinced of the paramount importance of the use of free incisions, and also that the vascular supply of the palate is amply sufficient to allow of these being made without any danger of sloughing, or of hindering primary union. That sloughing has occurred in the practice of others is undoubted; but this is more likely to have been due to a septic contamination and bruising of the tissues than to the extent of the incisions. I would again refer my readers to what has been already written (p. 118) as to the separation of the palatal tissues from the hamular process, and the complete detachment of the muco-periosteal flaps from the point of junction of the hard palate with the soft, where the tissue is thinner than elsewhere.

b. Defective paring of the edges of the cleft. This probably occurs from want of skill on the part of the surgeon, who fails to remove in one strip the mucous membrane from the margins.

c. Bruising of the edges from careless sponging, or rough manipulation with clumsy instruments. This is particularly liable to occur if the edges are pared prior to the detachment of the muco-periosteal flaps, in accordance with the mistaken directions given in many text-books.

d. Inaccurate coaptation of the edges of the wound, caused either by the stitches not being inserted at exactly opposite points on either side of the cleft, or by bringing the edges together too loosely, or so tightly that they are curled in.

e. Incomplete division of the levator palati will possibly explain some cases of non-union of the soft palate.

f. Want of careful supervision after the operation, and unsuitable food.

g. The occasional occurrence of uncontrollable vomiting or excessive hæmorrhage.

The most frequent situation of defective union is at the point of junction of the hard and soft palate; the tissue here is extremely thin, and laceration is liable to occur during the detaching process.

The apex of the cleft is another likely spot where union may fail; here from rigidity of the tissues accurate apposition is rendered difficult and sometimes impossible, particularly when the deformity is associated with alveolar cleft.

When apertures have resulted from any of the above detailed causes, it is useless to attempt to close them immediately, and moreover subsequent cicatrisation may much diminish their size or even close them entirely. M. Trélat[94] has seen one 9 mm. in diameter thus disappear, and my experience fully confirms such an observation. When, however, the contraction has come to a standstill, the margins may be pared, the lateral apertures reopened, the tissues loosened again from the bone, and the opening closed by as many sutures as may be necessary. Small fistulæ are often cured by the application of lunar caustic or fuming nitric acid.

Occasionally some trouble is experienced in the closure of the lateral apertures, one or both of them remaining patent and threatening to become fistulous. As a rule no anxiety need be entertained on this score. The only case in which I have had trouble was in a severe complete cleft in a young woman of twenty-seven; one of the openings was only closed twelve months after operation by applying nitric acid.

The occurrence of secondary hæmorrhage may be of so severe a character as to give rise to great anxiety, and it, as well as the treatment adopted for its arrest, may seriously interfere with the process of repair. Both intermediary and secondary hæmorrhage are met with; the former generally ceases after the application of cold, and seldom requires more active treatment. If, however, it arises from a large vessel such as the posterior palatine, which may have been incompletely divided, the re-introduction of the bistoury to complete the division and allow the artery to retract and subsequent sponge pressure will be necessary. In cases of true secondary hæmorrhage the palate wounds have probably progressed satisfactorily up to the fifth or seventh day, when suddenly there is an alarming gush of blood from one of the lateral apertures, and the patient becomes blanched and faint. The lateral apertures should be at once carefully syringed out, and the source of the bleeding discovered, if possible; the patient should lie with the mouth open and the head supported on a pillow. The use of styptics, such as perchloride of iron, should be studiously avoided, and, if absolutely necessary, I infinitely prefer to use the galvanic or Paquelin’s cautery. Some (e. g. Howard Marsh) have recommended and practised searching for the posterior palatine canal with a probe, and plugging it with a piece of wood, but of this I have had no experience. Although the bleeding may cease for a time it is liable to recur; under such circumstances it is best to enlarge the lateral apertures in order to expose the source of the hæmorrhage, which can then be dealt with as needful. Plugging of the lateral wounds should be reserved as a dernier ressort for fear of pressing injuriously upon the new vessels in the recent median cicatrix. These plugs, whether of lint, gauze, or sponge, soon become septic and sources of danger, and cannot therefore be long retained, whilst removal is liable to be attended with fresh bleeding.

Modifications of the Operation.

The operation of osteoplasty demands a brief notice under this heading. It was first practised by Dieffenbach in 1826, and subsequently revived in 1874 by the late Sir William Fergusson, whom I had the privilege of assisting in some eighty cases.

The principle of the operation consisted in carrying each lateral incision through the bony palate by means of a chisel, and prising the detached portions towards the middle line. Prior to this, however, the edges of the cleft were pared, and sutures were passed through holes previously drilled in the bony margins. The intention was to secure the union of flaps containing bone in the median line. Unfortunately, the results were anything but satisfactory, for in many instances the detached portions became necrosed and set up active inflammation and suppuration, leading to non-union. The bone, moreover, did not always cleave in the desired direction, and although the late Mr. Mason endeavoured to obviate this by punching holes, as a preliminary step, along the line the chisel was subsequently to take, on the postage-stamp principle, the results were not improved. One great objection to this lies in the difference of level which often exists between the two sides of the palate, especially when the vomer is attached to one margin. It is then excessively difficult to get the detached segments accurately together, whereas in Langenbeck’s operation the muco-periosteal flaps drop readily into position. Consequently, this method of osteoplasty has long since fallen into disuse.

In cases where the vomer is attached to either side of the cleft with a wide gap and scanty tissues, Mr. T. Smith has suggested the utilisation of the mucous membrane covering the vomer as a means of bridging the cleft. He incises it in a direction parallel to the edge, and at such a distance above the palate margin as is thought advisable; detaches it from above downwards by a hooked raspatory, and stitches it to the pared margin of the opposite side. Owing to the extreme delicacy of the membrane in this situation and the tendency it has to curl up, the success of this manœuvre is not always to be assured.

Mr. Davies-Colley has recently published[95] an account of an operation for which, indeed, he does not claim superiority over the usual method of closing ordinary clefts in the hard and soft palate, but which, he urges, should be adopted in the following contingencies—(1) for infants, (2) when the ordinary operation has failed, and (3) when the cleft in the hard palate is very wide. It consists in dissecting up a triangular muco-periosteal flap from one side of the cleft and entirely detaching it anteriorly, its base being at the junction of the hard and soft palate. On the other side a raw surface is prepared for its reception by reflecting a longitudinal flap of muco-periosteum in such a way that it can be turned as on a hinge into the cleft, and maintained in position there. The loose flap is then planted on it, and fixed by sutures. A bridge is thus formed across the hard palate consisting of a double muco-periosteal flap. The advantages claimed for this operation are less hæmorrhage, double thickness of flap, no loss of tissue, absence of tension, and that upward pressure of the tongue is more likely to do good than harm, whereas in Langenbeck’s the reverse is the case. There are obvious disadvantages, in particular that the hard palate is alone united, and that a foramen at the front part of the cleft usually remains; and although in Mr. Colley’s hands it may be occasionally successful, it scarcely appears to be one adapted for general use. As to its applicability in the case of infants, it is probably a procedure not devoid of risk, inasmuch as no operation can be safely undertaken in the majority of cases before the age of three years. The reader is referred to p. 101 for my reasons for this. When an operation has failed, it is surely more advisable to attempt closure of the whole cleft by repeating Langenbeck’s method rather than by a proceeding admittedly incomplete at first and requiring further treatment. When the cleft is wide anteriorly, it must be conceded that ordinary uranoplasty is often not sufficient to effect at one operation complete closure, and an anterior opening is not unlikely to persist, a condition, however, which Mr. Colley’s operation in no way prevents. My own practice, under such circumstances, is to obtain union as far forward as possible at the first operation, and to deal subsequently with the fistula by a modification of the same proceeding.

When a triangular opening has been left in front, owing to absence or previous removal of the os incisivum with the maxillæ more or less widely separated by a gap which extends anteriorly to the mucous membrane of the lip, it is often impossible to bring the edges of the cleft together however freely the raspatory is used, and many plans have been devised to meet this very definite difficulty.

Some surgeons have detached one muco-periosteal flap anteriorly, and so been able to bring it across the cleft and stitch it to the opposite side. But the interference with the vascular supply to the apex of the flap, and the rapid shrinkage which is apt to take place, frequently make matters worse than before. My experience of this plan has not been satisfactory.

Another method that I have recently employed with partial success consisted in reflecting a flap of mucous membrane from the back of the upper lip, and turning it down into the gap, fixing it laterally to the refreshed margins by fine wire sutures. Even if complete union does not take place, the portion thus reflected forms a point d’appui for later plastic interference.

It has also occurred to me to try the effect of cutting through the alveolar process immediately external to the canine tooth; that is, instead of detaching the palatal flap anteriorly to continue the lateral incision forward through the bony alveolus and after partially detaching this to prise it towards the median line. This proceeding is practically a modification of Fergusson’s osteoplasty, but differs from it inasmuch as there is little fear of necrosis on account of the spongy and vascular state of the alveolus. In the performance of it, after the palatal flaps have been detached by the raspatory, I incise the gum vertically along the line indicated, that is, continuing the lateral incision forward external to the canine tooth; a notch is then made with a small saw, and a chisel inserted cuts through and sufficiently detaches the portion of the alveolar process contiguous to the palate. The edges are now carefully freshened, and, if necessary, on the bevel, so as to allow for the slight rotation which occurs in drawing them together. Sutures are passed through the soft tissues deep enough to gain a firm hold of the flaps, so that when twisted they do not cut their way out in spite of the traction which is exercised. Care must be taken to pass the stitches in such a manner as to prevent undue rotation of the detached portions, otherwise the raw edges will not come into proper contact. Having at present given this plan but a limited trial, I do not wish to speak too confidently in its favour. Should such operative proceedings fail, an obturator should be fitted to the aperture.

Many other methods have been from time to time suggested as accessories to the ordinary operations of uranoplasty and staphyloraphy, and some of these need a cursory notice. Passavant stitched the halves of the velum to the posterior pharyngeal wall by an operation, known as “staphylo-pharyngoraphy.” Schönbein and Trendelenburg suggested “staphyloplasty” as an improvement, i. e. taking a flap of mucous membrane from the posterior pharyngeal wall and stitching this to the hinder wall of the velum. Both these operations aimed at totally shutting off the nose from the mouth; but in practice this was found to be not only uncomfortable, but also injurious. Smell and hearing were both interfered with, and breathing could only be carried on through the mouth; actual inflammatory troubles followed, which necessitated the communication being reopened.

Von Mosetig Moorhof attempted to improve upon these operations by allowing a fistula to remain at the position of the anterior palatine canal, which could be filled with an obturator by day to prevent the objectional nasal twang, and at night could be left open for breathing purposes.

Still more heroic are the operations which have been undertaken for the closure of palatal clefts by tissue taken from the face. Only three such cases, are, I believe, on record and of these two were for acquired deformities, and but one was for a congenital deficiency.

Blasius operated in a case where both the nose and the palate had been destroyed, by dissecting up a flap from the forehead attached to a long pedicle. This he easily twisted down into the mouth owing to the absence of the nose, and stitched into the gap. Success, however, did not follow from the drying effect of the double current of air. The same method was tried on the cadaver by Nussbaum, who demonstrated the possibility of drawing the flap through a slit in the nostril into the mouth and fixing it there; but he never had the opportunity of operating upon the living subject.

Professor Thiersch in 1868 successfully closed a hole in the hard palate, the result of a gunshot injury. He chiselled away the alveolar process, and turned in through this a flap consisting of the whole thickness of the cheek, its base being close to the nose.

Rotter records a third instance.[96] It was in a case of very wide right-sided harelip with cleft palate, in which Langenbeck’s operation had been successfully performed in so far as union in the middle line was concerned but the left palatine process was so nearly vertical that a lateral cleft half an inch in breadth resulted. This was repaired by a modification of Blasius’ operation. A long cutaneo-periosteal flap was taken from the forehead; the raw under-surface was grafted and allowed to heal entirely before being placed in situ. To accomplish this it was merely necessary to draw it through the still unclosed harelip to pare the edges of the flap and of the cleft, and to fix with sutures the former within the latter. When united firmly, the pedicle was divided, and the harelip closed. A good result followed, and was maintained two years later.

Such procedures can only be necessary in exceptional cases. Permanent scarring of the face is always to be regretted, and Langenbeck’s method or some slight modification of it, carefully and skillfully carried out, should meet nearly all contingencies. There is an instance recorded by Wolff[97] where the whole of the right-sided flap in a case of uranoplasty became gangrenous, leaving a wide opening which, however, was successfully closed subsequently by a repetition of the same process.