On harelip and cleft palate

by William Rose

It may not be out of place to notice the method adopted by Sir W. Fergusson for dividing the levator. A triangular-bladed knife set at right angles to a long stem was introduced behind the velum, and the two edges of the angular point made to cut their way between the pterygoid plates down to the bone, so as to divide the muscle close to its origin. From a theoretical point of view this appears all that can be desired; but practically the results following this procedure were not always satisfactory, inasmuch as the tension upon the stitches often appeared to be but little relieved, and one could never tell with certainty whether the muscles were effectually divided or not; in addition to which, unless the surgeon were very skilled in the use of the instrument and the anatomy of the region in which he was cutting, serious mischief might and did sometimes ensue. A knife such as the one to be employed, cutting at right angles to the handle, can never be used with absolute precision, particularly when the part to be dealt with is out of sight. The ease and certainty with which the structures can be divided by the former method of prolonging the lateral incision backwards have rendered this plan of Fergusson’s obsolete, although in his hands it was often very successful.

Should the hæmorrhage from these final incisions made in the soft palate be excessive, steps should be taken to ascertain whether the trunk or any large branch of the posterior palatine artery has been partially divided, as if so the bleeding is liable to recur at intervals, and may become serious. Under such circumstances, complete division of the vessel has almost always the immediate effect of staying the hæmorrhage. Sponge pressure and syringing with iced boracic lotion may be useful adjuncts in arresting the general oozing; but long continuance of the latter is detrimental to the vitality of the flaps and may endanger primary union. For a similar reason, plugging the lateral apertures, or recourse to powerful styptics, such as perchloride of iron, should if possible be scrupulously avoided.

All lateral tension being now relieved, and no serious hæmorrhage continuing, the sutured palate should present a solid, if somewhat blanched appearance in the middle line; the gag can be removed and the operation is complete.

Thus far we have been describing the operative treatment in the severer forms of cleft, in which both hard and soft palate are involved. When, however, the velum alone is cleft, merely the operation of staphyloraphy is required. In such cases the lateral incisions need not be of such an extensive character, and are usually made after the edges have been pared, and the stitches passed. It was for this type of case that Mr. Pollock introduced his method of dividing the levator palati by entering the knife through the mucous membrane of the velum a little in front and to the inner side of the hamular process, which can be felt in the mouth just behind the last molar tooth. The knife is pushed through the substance of the palate, and then by raising the handle and depressing the blade the muscle can be fully divided without making too extensive an incision in front. I should strongly recommend, however, a sufficient incision being made to admit the tip of the index finger, in order to ascertain with certainty that no tense fibres of the muscle remain undivided.

When the uvula alone is cleft no lateral incisions are necessary.

When the cleft extends for a short distance into the hard palate, lateral incisions must be made in the first stage of the operation, extending to a point a little anterior to the apex of the cleft, for the purpose of introducing raspatories to loosen the soft tissues around this point.

In some cases, after the soft palate has been brought together, a certain amount of tension is observed to be exercised upon the flaps by the traction of the muscles in the pillars of the fauces. If this be so, they should be divided by snipping them across with a pair of blunt-pointed scissors curved on the flat. By this means lateral tension is diminished, and the velum can be subsequently more easily approximated to the posterior pharyngeal wall.

Management of the Patient after Operation.

The patient should be placed in bed with the head low and no pillow, so that any oozing or accumulation of mucus, whether from the upper or lower surface, may gravitate into the pharynx; otherwise it may insinuate itself between, and tend to separate the lips of the wound.

A certain amount of shock is frequently observed during this period, and the circulation in the extremities should be promoted by warmth. A shivering fit, scarcely amounting to a rigor, is often observed, but is of no prognostic importance. During reaction, the blood which has been swallowed during the operation is usually vomited; when this occurs early the danger to the palate is not very great; but any vomiting at a later period has a serious disturbing effect, and the greatest care must be exercised in the supervision of the diet and general hygienic surroundings in order to prevent such accidents.