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.
CHAPTER VII.
ON OBTURATORS AND ARTIFICIAL VELA.
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.
Figs. 72 and 73.—Figures of artificial velum as seen from below and above, consisting of a metal palate plate with a velum hinged to it, and supported above by a spring of suitable strength. (Coles.)
Fig. 74.—Another form of artificial velum. (Coles.)
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.
CHAPTER VIII.
RESULTS OF TREATMENT—AFTER-TREATMENT.
The typical result which we desire to gain after an operation for harelip is a symmetrical appearance of lip and nose, and a normal contour and projection of the parts as seen from the front and in profile. The cicatrix should be practically invisible, and the red margin of the lip continuous throughout. Unfortunately, however, in many cases these results are not easily attainable. The tip of the nose tends to become drawn down and depressed, especially when in double harelip the philtrum is poorly developed, or when a mistaken attempt is made to incorporate it between the segments of the lip. This stunted but thickened columna encroaches on and obstructs the anterior nares, whilst in unilateral cases the aperture on the affected side is apt to become dilated and distended from the absence in some instances of the osseous floor, but also from subsequent cicatricial contraction of the previously divided bands between the cheek and maxilla. The behaviour of young cicatricial tissue, moreover, is not always the same. In some young and feeble children it remains vascular for a long time, and at first tends to stretch and become more evident;[100] subsequently contracting, it may leave an indurated cord-like ridge. In addition to this, a longitudinal contraction takes place in direct proportion to the thickness of the cicatrix, reducing the length of the scar and the depth of the lip, thus bringing about the 𝖵-shaped notch in the lip margin, and assisting in the dilatation of the nostril.
In double harelip, where the os incisivum has been removed, it has already been mentioned that the upper lip sinks back, the lower lip projects forwards, and the profile resulting therefrom becomes very unsightly ([Fig. 75]).
Fig. 75.—Profile of a case of double harelip after operation with removal of the os incisivum, showing the falling in of the upper lip and the prominent projection of the lower. (Coles.)
Many of these defects may be remedied by subsequent treatment. I am frequently in the habit of advising and practising secondary operations for the improvement of the facial expression in young children and adults presenting the unsatisfactory cicatrices detailed above. The operation comprises not only the removal of scar tissue, but also the obliteration of the 𝖵-shaped notch, elevation of the depressed nose, and the diminution in size, if necessary, of the nasal aperture. For a simple 𝖵-notch without other complications, I have sometimes made use of Nélaton’s operation ([Fig. 48]) with most satisfactory results.
The narrowing or partial obliteration of the nostrils in double harelip from the large size of the columna has sometimes to be remedied subsequently. One plan which I have practised several times for reducing the breadth of the columna is by excising a central lenticular-shaped portion, extending nearly the whole length through its entire thickness, and closing the gap with sutures. But a simpler method consists in paring the edges of the columna on either side to the required dimensions, and allowing the raw surfaces thus formed to cicatrise. The redundant tissue should be removed on the inner or nasal aspect, so that when cicatrisation takes place the skin is drawn round into the nares, and the resulting scar is unobtrusive.
The falling in of the upper lip after the operation for double harelip, when the os incisivum has been removed, can best be remedied by the adjustment of a plate carrying the required artificial incisors, and furnished with a central cheek-plate to restore the natural profile. Where the lower lip projects unduly in spite of the above-mentioned artificial adjustment, it may be requisite to reduce its size by the removal of a 𝖵-shaped portion from its centre. This is so easily accomplished as to need no detailed description; suffice it to say that the greatest care is needed in the accurate application of the sutures.
I cannot conclude this portion of my subject without mentioning the manual and mechanical aids which may be beneficially employed for the improvement of the mobility and appearance of the face and nose after such operations. The under-cutting of the integuments of the lip and cheek, and the subsequent cicatrisation involved, necessarily lead to a certain amount of rigidity of the parts. This can be remedied in a great measure by persistent gentle manipulation of the lip and cheek, care being taken always to press the parts towards the median line. This should be carried out by the mother or nurse daily after due instruction. A slight depression or collapse of the nostril on one side can be improved by the use of an apparatus supplied by Messrs. Hawksley, consisting of a head-band across the forehead, to which are attached vertical stems ending in smooth bulbs, which, by rack and pinion movement, can be so adjusted as to press the nostril into the desired position. The apparatus can be worn at night and for a certain time during the day.
The conditions which are essential to a complete success after plastic operations for cleft palate are as follows: complete closure of the cleft with no fistulous communication in any part of the line of union, and a velum capable, when necessary, of being approximated to the posterior pharyngeal wall so as to shut off the nasal cavity during speech and deglutition. That this is not invariably attained is an undoubted fact, and in spite of the merest shaving being removed when paring the edges of the cleft, the velum when united is frequently so scanty as to be unable to fulfil this condition. To remedy this, it was proposed some years ago by the late Mr. Mason to loosen the soft palate by lateral incisions, passing downwards and backwards through the free border, thus relaxing the tension, and allowing it to be drawn upwards, when requisite, into relation with the pharyngeal wall. I have adopted this plan in several cases, but with only transient success, inasmuch as the subsequent cicatrisation of the incisions neutralises the temporary benefit derived. The division of the pillars of the fauces, however, is occasionally needful and more satisfactory. This has been already alluded to ([p. 127]), and may either be performed at the time of the first operation, or subsequently if found to be necessary.
Even in cases where the tissue is abundant, and the united velum loose and moveable, the immediate effect on the speech is not always satisfactory. The other advantages of the operation (e. g. exclusion of nasal mucus from the mouth, prevention of regurgitation of fluids through the nose, improvement in taste and smell, and the psychical effects) are immediately apparent; but speech is a more complicated proceeding, and the first result of the operation is often to dislocate the mechanism which the patient had formerly made use of in its production, and hence, as has been often noticed, speech and voice may be temporarily deteriorated, even after a successful operation. This is a disappointment both to the patient and friends unless they have been previously warned. A subsequent thorough educational course at the hands of a professional voice-trainer, if possible, is therefore most important.
In some instances tension of the velum is no doubt the cause of the persistent nasal twang, but in many others habit is the principal factor, and this can alone be got rid of by a suitable education. The reluctance to breathe through the mouth, and the unwillingness to open it sufficiently during articulation, are conditions very liable to persist after operation. Such patients also speak too rapidly and run the words into one another, the velum evidently not being under control. The most difficult letters to pronounce are t, b, d, k, g, s, z, and l. The best means of dealing with the defective breathing is to make the patient undergo a course of “respiratory gymnastics.” Thus he should be made to practise deep abdominal breathing with the mouth wide open; he should stand in front of a looking-glass, and breathe with his mouth open and his tongue voluntarily depressed. He should next repeatedly exercise the movements of his tongue and lower jaw; this is often productive of great improvement in the facial expression. These exercises should be followed up by others directed to the improvement of speech. The distinct production of the various vowels and consonants and of all the sound combinations must be a matter of daily practice. He should be made to speak and read aloud according to the recognised laws of elocution, and by so doing obtain proper modulation of the voice and fluency of speech. Compression of the nasal apertures during these exercises is also advantageous.
The physical condition of the hard palate after the operation of uranoplasty is a subject of considerable interest. Langenbeck[101] claimed that a new formation of bone really occurred about three or four weeks after the operation, and attained in time considerable solidity. From experiments, however, by M. Marmy on the palates of dogs, doubt was thrown on the correctness of this assertion; and M. Ollier, so well known as an authority on subperiosteal work, declares that “if there may be doubt as to the ossification, all must admit that it forms a very resisting surface, which has the strength and takes the place of bone.” Opportunities for post-mortem investigation do not seem to have been taken advantage of for deciding this question; but clinical experience seems to indicate that no new bone is actually formed, the central portion of the palate consisting merely of dense fibro-cicatricial tissue covered with mucous membrane. In operating after a lapse of several years for the closure of oval apertures in the hard palate in patients in whom a previous operation had been but partially successful, I have never found osseous tissue, either when paring the margins or when detaching the flaps through lateral incisions.
The shape and size of the alveolar arch are sometimes considerably affected as an after result of uranoplasty. It would appear that in the young the contraction of the cicatrix between the palatal segments and of the new tissue in the lateral openings exercises a narrowing influence on the transverse diameter. The alveolar borders approach one another, and this approximation is most marked at the level of the first or second bicuspids, and indeed is so great occasionally as to produce an obvious incurvation of the alveolar ridge. M. Ehrmann of Paris, has investigated many instances of this change, and from his work[102] the figures mentioned below are obtained.
In one case a child was operated on for total cleft at three and a half years. Six months later the following measurements were taken:
| Transverse interval between | canines | 13 mms. |
| ” ” | 1st molars | 18 ” |
| ” ” | 2nd ” | 26 ” |
At twenty-three years of age the following were the measurements:
| Transverse interval between | canines | 7 mms. |
| ” ” | 1st premolars | 13 ” |
| ” ” | 2nd ” | 19 ” |
| ” ” | 1st molars | 23 ” |
| ” ” | 2nd ” | 32 ” |
The alveoli here formed a reversed 𝖵, and when the patient spoke, the tongue was more or less protruded. In another case, operated on at five years of age for the palate defect, a double harelip having been treated at an earlier date, the measurements were—
| At 5 years. | At 6 years. | At 11 years. | ||
|---|---|---|---|---|
| Intervals between | canines | 23 mms. | 19 mms. | 12 mms. |
| ” | 1st premolars | 27 ” | 24 ” | 14 ” |
| ” | 2nd ” | 32 ” | 27 ” | 19 ” |
| ” | 1st molars | — | — | 23 ” |
This result is more frequently seen in the severer forms of cleft palate associated with double harelip, especially where the os incisivum has been removed. Extreme youth increases the tendency to the production of these deformities, which may become troublesome, not only by interfering with the size of the buccal cavity, and so causing protrusion of the tongue during speech, but also by interfering with the “bite,” necessitating lateral movement of the jaw during mastication.
In one of Ehrmann’s cases an actual increase of the interdental diameters was found; this was one in which Fergusson’s osteoplasty had been performed with complete success; possibly the formation of new bone from the callus produced led to this, or it may have been merely an evidence of normal growth. The measurements were as follows:
| At 3 years. | At 11 years. | ||
|---|---|---|---|
| Intervals between | canines | 24 mms. | 26 mms. |
| ” | 1st premolars | 26 ” | 29 ” |
| ” | 2nd premolars | 29 ” | 32 ” |
| ” | 1st molars | — | 34 ” |
CHAPTER IX.
SYPHILITIC AFFECTIONS OF THE PALATE.
This small work will not be complete without some allusion to the destructive effects of syphilis upon the hard and soft structures of the palate, resulting either in loss of substance of the velum, or in the production of apertures which of necessity impair its functions in the same way as do congenital deformities. They occur at different stages of the disease, but mainly in cases which have been neglected, and of which the treatment has been unsatisfactory.
In the secondary period the most common manifestation of this disease in the palate is, in its mildest form, simply a moderate injection of the mucous membrane, similar to the roseola seen on the skin. It is situated mainly on the velum and anterior pillars of the fauces, and under efficient treatment soon disappears. Severer manifestations are, however, met with, from the mucous plaque, with its resulting “snail-track” ulcer, to the most serious forms of destructive change. Such severe forms occur usually towards the close of the secondary period, and in persons of vitiated constitution. The process starts in the neighbourhood of the uvula, and involves the velum and pillars of the fauces; the mucous membrane and submucous tissue become hyperæmic and infiltrated with the products of inflammation, and the hyperplasia may be such as even to suggest the presence of epithelioma. Ulceration soon follows, and if the disease be extensive the patient’s condition may become serious from the difficulties experienced in deglutition and respiration. The loss of substance may extend to a variable depth, and subsequent cicatrisation tends more often to produce pharyngeal stenosis than to leave permanent apertures in the velum; as a result, speech becomes indistinct, and the act of swallowing is much interfered with. In many of these cases the primary sore has been intentionally or accidentally overlooked, or no treatment adopted.
In the tertiary stage the disease usually commences as a gummatous infiltration of the periosteum of the hard palate, resulting in an inflammatory swelling which softens and breaks down, the mucous membrane over it giving way; portions of the bony palate are thrown off at a later date with the discharge, in the form usually of “crumbly” spongy sequestra of variable size. This process often extends beyond the palate to the bones of the nose, to the walls of the antrum, and to the alveolar border of the superior maxilla. After cicatrisation has taken place, apertures of varying extent are left bounded by dense fibro-cicatricial tissue, which in some measure tends by its contraction to diminish the size of the opening. Clear articulation is impossible under these circumstances.
Similar conditions occur in inherited syphilis, leading to destruction of the bony palate, but in these cases the disease usually extends downwards from the nose.
The treatment of these affections need not here be discussed in detail so far as regards the general means to be adopted. What we are chiefly concerned with is the question as to the possibility of surgical interference with a view to closing the apertures, so as to improve the speech and increase the patient’s comfort by preventing the regurgitation of fluids from mouth to nose, and the descent of nasal mucus on to the tongue. The result, however, of the experience of all surgeons tends to prove that in the majority of cases any operative interference is worse than useless, and is likely to increase existing mischief. The chief reasons for the want of success are (1) that so much loss of substance has already occurred; (2) that the tissue dealt with is cicatricial, and consequently of low vitality; and (3) that the constitutional condition of such patients is extremely unfavorable for plastic work. Although I have myself repeatedly attempted the closure of apertures in the hard palate, I cannot recall a single case in which complete success was attained when the operation was performed on middle-aged individuals. On the other hand, small holes in the soft palate can in many instances be successfully dealt with, and I should not hesitate to attempt the closure of a small opening in the hard, provided that there was a reasonable prospect of gaining sufficient tissue to be brought together without tension after paring the edges, and that no external manifestation of local or general disease was present. When any such operation is decided on, the only hope of success consists in an absolute freedom from all tension, gained by extensive lateral incisions.
The application of lunar caustic or nitric acid for the purpose of closing small foramina is of doubtful utility on account of the feebleness of the tissues dealt with.
In most instances, therefore, we are compelled to have recourse to the use of obturators, and these are now made to accurately fit the opening without undue pressure on the sides. Two discs of india-rubber united by a central stem generally answer the purpose satisfactorily, and a plate may be worn fixed to one or more of the teeth. In hospital patients a piece of sheet india-rubber, which they fit for themselves, and maintain in situ by suction, is a cheap and efficacious contrivance.
ADDENDUM.
RECTAL ANÆSTHESIA.
The plan of inducing anæsthesia per rectum, which has recently been brought before the profession in this country by Dr. Dudley Buxton, was originally suggested by Pirogoff in 1847, ether being the agent employed; but the introduction of chloroform in 1848 led to the disuse of ether in any way for many years. More recently Pirogoff’s suggestion has been resuscitated, and made use of by Bull, Weir, and others in America, Ollivier and Molière in France, by Iversen and Wancher in Copenhagen, and by Dudley Buxton in this country. The last-named anæsthetist recommends an apparatus (supplied by Mayer and Meltzer) consisting of a receiver for the ether, which is placed in water at about 120° F. The vapour thus given off is conducted by a ¾-inch rubber tube, about four feet long, through a specially constructed intercepter to prevent any liquid ether bubbling into the rectum, and enters it by an anal tube. A special device maintains sufficient pressure upon the perineal pad to prevent the escape of flatus or ether from the bowel. Anæsthesia may be induced from the first in this manner; or, as a preliminary step, chloroform or ether may be given by inhalation in the usual way, and the rectal administration subsequently relied on. The disadvantage of this combined method is the difficulty of judging when the absorption by the rectum is sufficient to be trusted alone; otherwise the patient may regain partial consciousness, and struggle. When the rectal plan only is used, the patient is often twenty or thirty minutes becoming unconscious, although ether may be smelt in the breath within five of its commencement. There is no excitement or struggling, and fewer after-effects. Care must be taken to regulate the amount of ether used, or abdominal distension and rectal catarrh may result; particularly is this the case if the operation be protracted. The method may prove of value, when properly employed, in operations involving the tongue, lips, pharynx, larynx, palate, jaws, &c. There are, however, obvious dangers in connection with its use, and unfortunately these fears have been realised in America by the combustion of the vapour leading to rupture of the bowel and other disastrous consequences.