—The responsibility of the anesthetist in these cases is great. Considering that he has to work through the same cavity as the surgeon it is sometimes very difficult to keep the child in a consistent state of narcosis. The inhaler devised by Dr. Souchon serves an admirable purpose. (See [p. 644].) I regard chloroform as the safest of the anesthetics, as it is less irritating and provokes less flow of saliva. It is a good plan to cocainize the parts previous to incision, in order to so benumb them as to make reflex impressions less pronounced.
The theory of these operations, like that for hare-lip, is simple. It consists in freshening the edges of the cleft, bringing them together and holding them in position; this requires clean work and a mouth kept clean—in other words, it calls for efficient antisepsis, for strict asepsis is impossible. All carious teeth should be removed or put in good condition, and large tonsils, with their distended crypts and reservoirs of decomposing material, and all adenoid tissue should be removed.
Owen has shown the benefit in nursing infants of using an old-fashioned “slipper bottle,” having a soft giant teat with a hole on the under surface. As the infant sucks from this the teat fills the cleft, and as the child compresses it in sucking the milk is directed downward. When this does not suffice milk may be given in a warm teaspoon, passed far back over the tongue, or from a medicine dropper.
Owen sustains Brophy in the contention that the most favorable time for operating on a cleft palate is between the age of two weeks and three months, there being at that time less shock, and the bones are extremely flexible. Accepting this statement as authoritative the operation upon young infants will be described.
Previous to the operation a warm, nourishing, and stimulating enema should be given the patient. After the infant is anesthetized the tongue is drawn forward by a long suture and the mouth kept open by a mouth-gag. The edges of the cleft are then pared with a sharp knife, after which effort should be made to press the upper maxillæ together, in order to test their flexibility and the possibility of approximating them in this manner. This will rarely be sufficient, however, and it becomes necessary to raise the cheek, on each side, toward the posterior extremity of the hard palate just behind the malar process, and pass a knife through the outer bony surface, making a sufficient division of the antral wall through a minimum of opening. Rather than cut too much bone at first the knife may be re-introduced. The actual approximation of the maxillæ is produced by silver-wire sutures. A firm, stout needle carrying a thick, silk pilot suture is passed through at the point above mentioned and made to appear in the fissure, where the loop may be pulled down, after which it may be again passed through the other side and made to emerge at a point corresponding to that at which it entered. The suture thus passed in one way or the other is made to carry a strong silver wire from one side across to the other, on a level above the hard palate, emerging on each side within the cheeks. Another wire suture is similarly passed more anteriorly. Two small oblong leaden plates, 1.5 Cm. in length and 35 or 40 Cm. in width, drilled with two holes, are then provided, one of them laid along the outside of each maxilla, the wire sutures passing through the holes which they contain. On one side the ends of the wire are then twisted firmly and cut short, thus forming a complete grip upon the plate on its side; then the jaws are pressed firmly together, while the wire sutures on the other side are similarly fastened over the lead plates and twisted tightly to make permanent the effect produced by pressure with the fingers. These sutures should be made sufficiently tight to permit of approximation of the borders of the mucoperiosteal surfaces, already freshened, in such a way that they may be held together with fine wire or horse-hair sutures and without undue tension.
The lead plates are left in situ for three or four weeks. If necessary the wire suture may be tightened to allow for relaxation produced by pressure effect. Some ulceration may occur beneath the plates, but this heals after their removal. Theoretical objection to this method may be made because of the tendency to narrowing of the upper jaw. In fact, however, it is only restored to its proper dimensions, as that part of the face has been previously widened by the width of the cleft. Irregular eruption of teeth or irregularity of development may be treated by a dentist.
When the vomer affixed to the intermaxillary bone projects in a snout-like manner it is necessary to remove a V-shaped section from it, the base of the triangle being along the margin of the cleft, in order that the projection may drop backward and the corresponding part fall into line with the rest of the alveolar process. This is best done as a preliminary and distinct operation.
Uranoplasty in older patients consists essentially of forming two anteroposterior mucoperiosteal flaps, from the hard and soft palates, on either side of the cleft, with their inner edges neatly pared, which should be separated from the bony roof of the mouth, and slid toward each other until they can be held together by sutures. These operations are best performed with the patient’s head hanging over the end of a table, so that blood may not find its way into the trachea or stomach, but be sponged away. This is the position of the so-called “down-hanging head” described by Rose. In fat-necked individuals it may be impracticable. After paring the borders adjoining the fissure an incision is made just within the alveolar border, close up to the teeth, parallel to the former, of sufficient length to permit of the formation of the flap above mentioned; then with raspatories or elevators it is detached from the hard palate. In a mouth with a gothic arch or roof it is often easier to form these flaps and to bring them together than in others. It may be possible in such cases to not only suture the edges, but also some portion of their raw surfaces, thus ensuring better union. (See [Fig. 468].)
Branches of the anterior palatine artery will bleed freely during this part of the performance. Firm pressure and the use locally of adrenalin solution will usually overcome this difficulty. As the incision is extended backward the posterior arteries will cause the same difficulty. The wider the defect the farther backward should the lateral incisions be extended. Here the principal obstacle to easy approximation of edges is the activity of the levator and tensor palati muscles. Formerly it was a part of operations to divide the tendon of the latter as it passes around the hamular process. It has been found, however, that this is often unnecessary. A tenotomy of this tendon, however, may be made just as that of any other tendon with the expectation that the gap thus made will be filled with fibrous tissue. While, on one hand, it is of great advantage to spare this tendon, on the other hand its muscle may be the principal factor operating to pull apart those surfaces which have been neatly brought together.
Fergusson and Langenbeck have not hesitated to make osteoplastic flaps when necessary, dividing the hard palate along the line of the lateral incisions with a fine chisel. This is not often required, and complicates the case to an undesirable extent, although it may be necessary in wide fissures with a minimum of tissue ([Fig. 469]).