Elements of Surgery

by Robert Liston

If the flap is short and free, without osseous projection, the operation may be concluded at once, thus:— The edges are pared on both sides, and the parts brought together as in single harelip, the small intervening flap not preventing apposition below. One pin is passed at the prolabium, the other traverses the flap. In all cases, in fact, the operation may be concluded at once.

When the bone projects, and the flap is long, the parts may be rendered favourable for the operation by gentle and continued pressure; the osseous prominence being reduced, so as to restore the natural position of the soft parts.

When, as not unfrequently occurs, there is projection of the bone, and the soft and hard parts seem to be incorporated with the apex of the nose—when, in short, little or no intermediate flap exists, the protruding portion of bone may be removed by cutting forceps down to the level of the palatine arch; and then the soft parts can be brought together by one operation, as for single harelip.

In some cases, when the space between the palatine plates of the superior maxillary bone is wide, it may be necessary, by mechanical contrivance, fitting on metallic apparatus possessing a strong spring, to approximate the bones before attempting to unite the lip. The cases must be very rare, where the soft parts cannot be otherwise brought together: when they can be united, their equable and continued pressure will have the effect of gradually approximating the hard parts.

When the hard palate is deficient, the patient is subjected to great inconvenience from food escaping into the cavities of the nose, and, in later life, horrid wretchedness of articulation occurs. It can readily be understood, that surgery is of very little avail here. Recourse must be had to mechanical contrivance. A plate of metal (gold or platina), or a piece of ivory, or of sea-horse bone, may be fitted to the opening, and retained either by accurate adaptation, having sponge or caoutchouc attached to the upper surface, or by wires, elastic or not, resting on the neighbouring teeth. It may be made of a piece with artificial teeth, if any are required. The sponge is objectionable, as retaining the discharge, and thereby imparting an unpleasant odour to the expired air. But it is no easy matter, and often altogether impracticable, to retain such apparatus when the soft palate is also deficient. The time at which such contrivance is to be adapted may admit of some dispute. If done early in life, the natural tendency of the parts to approximate may be interfered with and subverted; if dispensed with till a later period, the patient gets into a habit of snuffling and speaking so indistinctly, that the closing of the aperture is productive of little or no improvement. Perhaps the period of commencing the child’s education should be delayed till he be seven, eight, nine, or even ten years of age, and then the artificial palate may be applied advantageously in every respect.

Fissure of the soft palate is usually accompanied with separation of the bones from which it is suspended. The size of the fissure is various, and depends very much upon the state of the hard parts. In some cases, the extent of separation is great; in others, the edges are readily approximated by making the patient throw the muscles into action. The latter class admit of operation with a view to permanent union of the edges of the fissure. But it is a proceeding which, to insure success, requires not only great steadiness, coolness, and dexterity on the part of the operator, but the utmost courage, submission and self-denial on the part of the patient. These qualifications can scarcely be expected in patients under twelve or fourteen; and, consequently, the operation should not be attempted till after that time of life.

Before proceeding to operate, it should first be ascertained that the fissure is not of such extent as to prevent apposition of its edges, without great dragging of the parts; for, if the separation be wide, temporary approximation may perhaps be effected by ligatures strongly applied, but the apposition will not be complete or accurate throughout the whole fissure, and adhesion will not take place; the palate will be too much stretched, as to throw off the ligatures by ulceration at the transfixed points of its margins. The patient must be made aware of the nicety of the operation, of the responsibility that rests upon himself, and be exhorted to steadiness and patience. A single exclamation of pain may subvert the whole proceedings. He is seated opposite to a strong light, and made to open the mouth wide; if necessary, the jaws may be kept separate by a wooden wedge, placed so as not to interfere with the operator. The head is thrown back, and held steadily by an assistant. The operator depresses the tongue by the forefinger of the left hand. A long, narrow, sharp-pointed bistoury is passed through the velum, close to its attachment with the palatine plate, and about a sixteenth part of an inch from the edge of the fissure: it is then carried downwards to the point of the uvula, so as to detach a narrow slip from the whole edge. The same is done on the opposite side of the fissure during the proceeding, and to facilitate it the point of the uvula on each side may be held by long and properly pointed forceps. After allowing the patient a short rest, the coagula and mucus are cleaned away from the parts, to prepare for union. Long bent needles, in fixed handles, and armed, are passed through the pared edges on each side. On one side the ligature is thin, the opposite thick and strong; the former is attached to the loop of the latter, and withdrawn, leaving the strong ligature passed through both apertures; and by this the margins are gradually approximated, and retained by a firm knot. A second point of suture, and a third, if necessary, is applied in the same way, and as represented in the “Practical Surgery,” p. 558. Or a single short curved needle may be used. It is introduced by means of a portaiguille, with a long handle, and passed through, first from the outside of one edge, and then from the inside of the other. A ligature, either of thread or of pewter wire, can thus be conveyed at once; if the latter is employed, it is secured by twisting, and the ends cut off by pliers; the needle is attached to the wire by a female screw in its end. It is advisable to make incisions in the direction of the fissure on each side, through the mucous lining, in order to take off the strain from the stitches.

Afterwards, success depends on the patient. All attempts at articulation, and even deglutition, must be strictly forbidden for three, four, or five days.

Inflammation of the Soft Palate, Uvula, and Tonsils, requires in general little surgical treatment. Reiterated attacks may sometimes be traced to the progress of a wisdom-tooth, or to the presence of stumps in the posterior part of the upper or lower jaw. Perhaps the most common cause is sudden suppression of the discharges from the skin, and from the adjoining mucous surfaces, in consequence of exposure to cold. The affection is accompanied with pain and difficulty in swallowing, and frequent and difficult excretion of mucus. The secretion of the saliva is increased, the attempts to swallow it are frequent, and the inflamed parts being thereby put in motion, the pain is aggravated. From the inflammatory action extending along the Eustachian tube, the patient describes the pain as shooting towards the ear. The parts are red, and soon becomes swollen; in some cases to so great an extent, as completely to prevent deglutition; occasionally the breathing is impeded; but the inflammatory swelling must be very great indeed, to obstruct the openings into both mouth and nostrils, and thereby threaten suffocation. The voice is hoarse, croaking, and husky; and, when the swelling is considerable, the patient speaks only in a whisper. The internal swelling is often accompanied by an external painful tumour of the lymphatic glands, and the pain is much increased by external pressure. There is more or less concomitant fever, preceded by slight shivering.