On harelip and cleft palate

by William Rose

Instruments.

Fig. 57.—T. Smith’s gag with tongue plate (Arnold).

Fig. 58.—Mason’s gag.

Fig. 59.—Rose’s gag, double ended. Large end for adults; small end for children. Sliding ring-catch fixing instrument in position.

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.

Fig. 60.—Various forms of raspatories employed in detaching the muco-periosteal flaps in uranoplasty. The three in the left-hand lower corner are used for detaching the flaps anteriorly (After Durham).

Fig. 61 A, B, C.—Fine hook forceps. Long smooth-nosed forceps. Knife for paring the edges of the cleft (Mason).

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.

Fig. 62.—Angular long-handled catch forceps (the teeth are a little coarser than in the original).

Fig. 63.—Various forms of needles employed in palate operations. The left-hand figures show the double-curved needles used in suturing the uvula.

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.)

Fig. 64.—Shows effect of drawing stitches together when needles cutting parallel to the edge of the cleft have been used, resulting in an oval opening at the site of each needle puncture.

Fig. 65.—Contrasts the effect produced when needles cutting at right angles to the cleft margin are used. There is no tendency to opening up of the needle tracks, but rather to close them.

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.

Fig. 66. Wire twister (Maw).

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.