Fissures in the Palate.—The operations requisite for the cure of fissures in the soft and hard palates are so complicated in their details, that a small treatise would be required thoroughly to describe the various procedures.
Different cases vary so much in the nature and amount of their deformity, that at least five different sets of cases have been described. It is sufficient here merely to describe the absolutely essential principles of the operations for the cure of fissures of the hard and soft palate respectively.
In all operations on the palate, two conditions used to be considered requisite for success:—1. That the patient should have arrived at years of discretion, at twelve or fourteen years at least; that he be possessed of considerable firmness, and be extremely anxious for a cure, so as to give full and intelligent co-operation. 2. That for some days or weeks prior to the operation the mouth and palate should have been trained to open widely and to bear manipulation, without reflex action being excited. Professor Billroth of Vienna,[120] and Mr. Thomas Smith[121] of London, have had cases which prove the possibility of performing this operation in childhood, under chloroform, with the assistance, in the English cases, of a suitable gag, invented by Mr. Smith. The effect of the operation on the voice of the child has been very encouraging, as much more improvement takes place than in cases where the operation is performed late in life.
Fissure in the soft palate only appears as a triangular cleft, the apex of which is above, the base being a line between the points of the bifid uvula, which are widely separated. To cure this it is required—
1. That the edges of the fissure should be brought together without strain or tightness. In small fissures this can generally be done easily enough; but where the fissure is extensive, some means must be used to relieve tension. For this, Sir William Fergusson long ago proposed the division of the palatal muscles, the levator, tensor, and palato-pharyngeus muscle of each side. The incisions in the palate for this purpose certainly aid apposition, but many surgeons entertain doubts whether the division of the muscles has much to do with the good result, and believe that the simple incisions in the mucous membrane, in a proper direction, are all that is required (see Fig. xxix.).
Fig. xxix. [122]
2. That the edges of the fissure be made raw, so as to afford surfaces which will readily unite. Complicated instruments, such as knives of various strange shapes, have been devised for this purpose; an ordinary cataract knife, very sharp, and set on a long handle is perhaps the best. It greatly facilitates the section if the parts are tense, so the point of the uvula should be seized by an ordinary pair of spring forceps, and drawn across the roof of the mouth, while the knife should enter in the middle line, a little above the apex of the fissure, and make the cut downwards as in harelip.
3. That sutures should be inserted to keep the edges in apposition, yet not so tightly as to cause ulceration. They may be either of metal, silver being preferable, or of fine silk well waxed. The metallic sutures are now generally preferred. Some dexterity is required in their introduction, and various instruments have been devised; the best seems to be a needle with a short curve fixed on a long handle, which should be entered on the (patient's) left side of the fissure in front, and brought out on the right side.
If silk sutures be used, the chief difficulty, that of passing the thread through the second side from behind forwards, can be avoided in the following manner.[123] A curved needle is passed through one side of the fissure, and then towards the middle line, till its point is seen through the cleft. One of the ends of the thread is then seized by a long pair of forceps, and drawn through the cleft; the needle is then withdrawn, leaving the thread through the palate, and both ends are brought outside at the angle of the mouth. Another needle is then passed through a corresponding point at the opposite side of the palate, till its point again appears at the cleft; this time a double loop of the thread is also brought out through the cleft by the forceps into the mouth. If then the single thread of the first ligature which is in the cleft be passed through the loop of the second one also in the cleft, it is easy, by withdrawing the loop through the palate, to finish the stitch (see Fig. xxix.). All the stitches should be passed and their position approved before any one be tied, and it is most convenient to secure them from above downwards. To prevent confusion, each pair of threads after being inserted should be left very long, and brought up to a coronet fixed on the brow, which is fitted with several pairs of hooks numbered for easy reference. This will prevent twisting of the threads or any mistake in tying.