Fig. 56.—T. Smith’s operation for double harelip. The outer segments are pared and the parings removed. Prolabial flaps are turned down from the sides of the central tubercle. Evidently it can only be of use where the soft tissues are abundant. (Mason.)
CHAPTER VI.
OPERATIVE TREATMENT OF CLEFT PALATE.
Period of operation.—Preparation of patient.—Anæsthesia.—Duties of the assistant.—Instruments.—Description of uranoplasty; of staphyloraphy.—After-treatment.—Complications.—Modifications of operation.
The period of life at which an operation can be safely undertaken for Cleft Palate is a matter which demands careful consideration. Before the introduction of anæsthesia the assent of the patient was required, and therefore the operation was seldom performed before the age of puberty. With the aid of chloroform this is obviated, and we can now operate at an earlier period; undoubtedly as regards the subsequent power of articulation the earlier the operation is performed the better. On the other hand, the palatal tissue in infant life is so delicate, and the cavity of the mouth so small that a plastic operation is attended with more than usual difficulty. Further it is almost impossible to keep an infant sufficiently quiet to allow of primary union, as it is constantly interfering with the stitches by pushing the tongue against the wound, and sucking the edges apart. Statistics of results, moreover, tend to prove that such operations conducted on young infants are not only directly dangerous to life, but also indirectly, by depressing the general vitality and increasing the liability to subsequent disease. Thus Ehrmann[86] records ten cases operated on under two years of age with two deaths, two failures, and six cures, which latter he considers due to the fact that the children were fed after the operation by œsophageal tubes passed through a protective plate of hardened rubber so as to prevent interference with the sutures. Of these six cases cured, only one was living after four years had elapsed, and in this the soft palate only had been closed. He considers that the loss of blood, and the shock of the prolonged operation or operations interfered in a serious manner with the vitality of the patients. These are, perhaps, somewhat scanty facts to argue from, but they tend to show that there is a greater risk associated with operations performed at an early period of life, although we have the authority of many well known surgeons for attempting them. Thus Billroth has operated at the age of four weeks, Roye of Lausanne at eight days; but my own experience is certainly in favour of deferring operation until the child is at least three years old, or as soon after that period as possible if it is at all of a tractable disposition; the moral control at this age is usually sufficient for our purpose.
As to whether the whole cleft should be dealt with at one operation or not, the practice of surgeons differs considerably; and indeed each case needs to be decided upon its own merits. Where the cleft merely involves the soft palate, or possibly extends but for a short distance into the hard, one operation will usually suffice; but in extreme cases of complete cleft of the hard and soft palate with wide separation of the edges, it may be advisable to deal at different times with the hard and soft, some preferring to close the hard at the first operation, and others the soft. This must depend upon the surgeon’s confidence in himself and in his patient. Personally I always prefer, if practicable, to obtain union in the hard palate at the first operation; then if after taking the necessary steps for loosening the muco-periosteal flaps the parts appear to come easily together, the edges of the whole cleft can be pared, and the whole process completed at one sitting. I cannot too strongly insist on the paramount importance of obtaining firm union in the anterior part of the palate, for if the smallest opening be left in that situation, distinctness of speech in after-life will be seriously impaired.
Preparation of Patient.
The state of the health and the local conditions of the mouth, nose, and pharynx must be carefully examined before the operation is decided on.
The little patient’s general condition must be as satisfactory as possible, and a course of tonic preparatory treatment (including possibly a change to the seaside) is often advisable. Sources of infection from measles, &c., should be carefully avoided, and for a few days prior to the operation they should be kept under observation and at rest, to prevent any likelihood of catarrhal developments.
The local conditions, too, must be satisfactory. There should be no excessive secretion from the naso-pharyngeal mucous membrane, as such is usually associated with an œdematous infiltration of that structure, most unfavourable to the attainment of primary union; and, moreover, this excess of mucus tends to insinuate itself between the edges of the flaps. If present, it should be treated by rest in a warm mean temperature, bland diet, and the application locally of gargles of boracic acid and chlorate of potash, combined with the careful use of astringents such as tannic acid and alum; the tongue also should be clean. The state of the tonsils should be looked to, and when greatly enlarged they ought to be previously removed, for they may materially interfere with the union of the palate, either from their size, or from the possible supervention of inflammation; when only moderately enlarged there is, I believe, no necessity for their removal; on the contrary they subsequently assist in closing the aperture between the nose and mouth during speech. Similarly post-nasal adenoid growths should not be interfered with, unless absolutely necessary ([p. 70]).