On harelip and cleft palate

by William Rose

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.