On harelip and cleft palate

by William Rose

When apertures have resulted from any of the above detailed causes, it is useless to attempt to close them immediately, and moreover subsequent cicatrisation may much diminish their size or even close them entirely. M. Trélat[94] has seen one 9 mm. in diameter thus disappear, and my experience fully confirms such an observation. When, however, the contraction has come to a standstill, the margins may be pared, the lateral apertures reopened, the tissues loosened again from the bone, and the opening closed by as many sutures as may be necessary. Small fistulæ are often cured by the application of lunar caustic or fuming nitric acid.

Occasionally some trouble is experienced in the closure of the lateral apertures, one or both of them remaining patent and threatening to become fistulous. As a rule no anxiety need be entertained on this score. The only case in which I have had trouble was in a severe complete cleft in a young woman of twenty-seven; one of the openings was only closed twelve months after operation by applying nitric acid.

The occurrence of secondary hæmorrhage may be of so severe a character as to give rise to great anxiety, and it, as well as the treatment adopted for its arrest, may seriously interfere with the process of repair. Both intermediary and secondary hæmorrhage are met with; the former generally ceases after the application of cold, and seldom requires more active treatment. If, however, it arises from a large vessel such as the posterior palatine, which may have been incompletely divided, the re-introduction of the bistoury to complete the division and allow the artery to retract and subsequent sponge pressure will be necessary. In cases of true secondary hæmorrhage the palate wounds have probably progressed satisfactorily up to the fifth or seventh day, when suddenly there is an alarming gush of blood from one of the lateral apertures, and the patient becomes blanched and faint. The lateral apertures should be at once carefully syringed out, and the source of the bleeding discovered, if possible; the patient should lie with the mouth open and the head supported on a pillow. The use of styptics, such as perchloride of iron, should be studiously avoided, and, if absolutely necessary, I infinitely prefer to use the galvanic or Paquelin’s cautery. Some (e. g. Howard Marsh) have recommended and practised searching for the posterior palatine canal with a probe, and plugging it with a piece of wood, but of this I have had no experience. Although the bleeding may cease for a time it is liable to recur; under such circumstances it is best to enlarge the lateral apertures in order to expose the source of the hæmorrhage, which can then be dealt with as needful. Plugging of the lateral wounds should be reserved as a dernier ressort for fear of pressing injuriously upon the new vessels in the recent median cicatrix. These plugs, whether of lint, gauze, or sponge, soon become septic and sources of danger, and cannot therefore be long retained, whilst removal is liable to be attended with fresh bleeding.

Modifications of the Operation.

The operation of osteoplasty demands a brief notice under this heading. It was first practised by Dieffenbach in 1826, and subsequently revived in 1874 by the late Sir William Fergusson, whom I had the privilege of assisting in some eighty cases.

The principle of the operation consisted in carrying each lateral incision through the bony palate by means of a chisel, and prising the detached portions towards the middle line. Prior to this, however, the edges of the cleft were pared, and sutures were passed through holes previously drilled in the bony margins. The intention was to secure the union of flaps containing bone in the median line. Unfortunately, the results were anything but satisfactory, for in many instances the detached portions became necrosed and set up active inflammation and suppuration, leading to non-union. The bone, moreover, did not always cleave in the desired direction, and although the late Mr. Mason endeavoured to obviate this by punching holes, as a preliminary step, along the line the chisel was subsequently to take, on the postage-stamp principle, the results were not improved. One great objection to this lies in the difference of level which often exists between the two sides of the palate, especially when the vomer is attached to one margin. It is then excessively difficult to get the detached segments accurately together, whereas in Langenbeck’s operation the muco-periosteal flaps drop readily into position. Consequently, this method of osteoplasty has long since fallen into disuse.

In cases where the vomer is attached to either side of the cleft with a wide gap and scanty tissues, Mr. T. Smith has suggested the utilisation of the mucous membrane covering the vomer as a means of bridging the cleft. He incises it in a direction parallel to the edge, and at such a distance above the palate margin as is thought advisable; detaches it from above downwards by a hooked raspatory, and stitches it to the pared margin of the opposite side. Owing to the extreme delicacy of the membrane in this situation and the tendency it has to curl up, the success of this manœuvre is not always to be assured.

Mr. Davies-Colley has recently published[95] an account of an operation for which, indeed, he does not claim superiority over the usual method of closing ordinary clefts in the hard and soft palate, but which, he urges, should be adopted in the following contingencies—(1) for infants, (2) when the ordinary operation has failed, and (3) when the cleft in the hard palate is very wide. It consists in dissecting up a triangular muco-periosteal flap from one side of the cleft and entirely detaching it anteriorly, its base being at the junction of the hard and soft palate. On the other side a raw surface is prepared for its reception by reflecting a longitudinal flap of muco-periosteum in such a way that it can be turned as on a hinge into the cleft, and maintained in position there. The loose flap is then planted on it, and fixed by sutures. A bridge is thus formed across the hard palate consisting of a double muco-periosteal flap. The advantages claimed for this operation are less hæmorrhage, double thickness of flap, no loss of tissue, absence of tension, and that upward pressure of the tongue is more likely to do good than harm, whereas in Langenbeck’s the reverse is the case. There are obvious disadvantages, in particular that the hard palate is alone united, and that a foramen at the front part of the cleft usually remains; and although in Mr. Colley’s hands it may be occasionally successful, it scarcely appears to be one adapted for general use. As to its applicability in the case of infants, it is probably a procedure not devoid of risk, inasmuch as no operation can be safely undertaken in the majority of cases before the age of three years. The reader is referred to p. 101 for my reasons for this. When an operation has failed, it is surely more advisable to attempt closure of the whole cleft by repeating Langenbeck’s method rather than by a proceeding admittedly incomplete at first and requiring further treatment. When the cleft is wide anteriorly, it must be conceded that ordinary uranoplasty is often not sufficient to effect at one operation complete closure, and an anterior opening is not unlikely to persist, a condition, however, which Mr. Colley’s operation in no way prevents. My own practice, under such circumstances, is to obtain union as far forward as possible at the first operation, and to deal subsequently with the fistula by a modification of the same proceeding.

When a triangular opening has been left in front, owing to absence or previous removal of the os incisivum with the maxillæ more or less widely separated by a gap which extends anteriorly to the mucous membrane of the lip, it is often impossible to bring the edges of the cleft together however freely the raspatory is used, and many plans have been devised to meet this very definite difficulty.

Some surgeons have detached one muco-periosteal flap anteriorly, and so been able to bring it across the cleft and stitch it to the opposite side. But the interference with the vascular supply to the apex of the flap, and the rapid shrinkage which is apt to take place, frequently make matters worse than before. My experience of this plan has not been satisfactory.