Fig. 66. Wire twister (Maw).
The thickness of the wire used must vary directly with the delicacy or otherwise of the palatal tissues; the thinner the palate, the finer the wire, and vice versâ. In different portions of the same palate, wires of varying thicknesses have often to be used. The principal varieties that I make use of are Nos. 30 and 32 on the ordinary wire gauge. Whichever is used, it should be uniformly and well annealed, otherwise it is liable to break whilst being twisted, and does not straighten out on removal. In the region of the uvula it is better to employ some softer material, such as fine silk or catgut, as the projection of the ends of the wire has a tendency to irritate the back of the tongue and cause coughing and nausea.
A narrow straight probe-pointed bistoury may be needed to extend the lateral incisions into the soft palate, in order to relieve lateral tension.
The Operation.
It will be convenient first to describe in detail the technique of the operation in a typical case of combined cleft of the hard and soft palate, i. e. the operations of uranoplasty and staphyloraphy combined, and subsequently indicate the modifications necessary under special circumstances.
The method which is now almost universally employed is that known as Langenbeck’s, effecting complete closure by dissection of muco-periosteal flaps obtained from either side of the cleft, and sutured in the middle line. Although called after the great German surgeon, and rightly so, inasmuch as he first clearly enunciated the principles underlying the operation, it is certain that similar plans had been previously employed by others. The late Mr. Avery, of Charing Cross Hospital, seems to have been the first in this country to completely close a cleft in the hard palate, and he employed and described[88] a method very similar to Langenbeck’s. This was undertaken in 1848, and in 1853 Messrs. Weiss made improved and special raspatories for the operation. Langenbeck’s paper, on the other hand, did not appear until 1862. Previous to this various plans of surgical treatment had been employed. Operations upon the soft palate were undertaken much earlier than upon the hard, and although priority has been claimed both for Prof. Graefe[89] (1816) and M. Roux[90] (1819), who performed staphyloraphy independently, yet it is certain that a similar proceeding had been adopted by others in the latter half of last century. The first reference to a successful case that we possess is in 1760, when a dentist named Lemonnier[91] united the borders of a cleft in a child. Desault and others record similar cases in the first decade of this century. As regards the hard palate, M. Krimer[92] seems to be the first who attempted operative treatment (1824); he dissected up small muco-periosteal flaps on either side of the cleft, reversed them from without inwards, and united them in the middle line by sutures. M. Beaufils made use of a single flap twisted on itself so as to fill the aperture. Dr. Mason Warren in 1843 published a method of operating which seems in his hands to have been moderately successful, although only after repeated operations. He dissected up the mucous membrane, and freed the soft palate by dividing the posterior pillars with strong curved scissors, and then sutured in the median line. Several methods of “bony suture” have also at different times been suggested. Dieffenbach[93] led the way in 1826, and was followed by many other surgeons, Fergusson and Mason being prominent amongst them in this country. But the results were never satisfactory, and the method has now been entirely superseded by Langenbeck’s operation, which is applicable in almost all cases.
It may be divided into four stages:—
Stage 1. Incision, and detachment of muco-periosteal flaps.
Stage 2. Paring the edges of the cleft.