CHAPTER VII.
ON OBTURATORS AND ARTIFICIAL VELA.
Before the year 1830, when operative treatment for the closure of cleft palate first attracted attention, and began to be recognised as a legitimate surgical procedure, the only means of alleviating the troublesome symptoms resulting therefrom was by the use of artificial mechanical appliances; and in spite of the increased safety and certainty, the outcome of increased knowledge, with which such operations are now performed, the use of these has not been entirely superseded, and in America they are still much in vogue. These appliances are called obturators or artificial vela according to their position and function in the mouth.
“An obturator is a stopper, plug, or cover, stationary, and fitting to an opening, with a well-defined border or outline, and closing the passage.
“An artificial velum is an elastic moveable valve, under the control of surrounding or adjacent muscles, closing or opening the posterior nares at will, and applicable to cases of congenital cleft, occasionally when the soft palate has been destroyed by ulceration, but never merely to perforations of the hard, or soft palate.”[98] Such are the Utopian definitions given by American dentists.
It may be interesting to pass in review some of the ingenious appliances which have been from time to time suggested, and to indicate some of the various steps in the progress of their production.
It is evident that the ancient Greeks were acquainted with some means of closing or remedying acquired or congenital defects of the palate; but nothing is known definitely of the method adopted. In the year 1565 Petronius, in his work ‘De Margo Gallico,’ proposed to close the opening by wax, cotton, or with a gold plate adapted to the curve of the palate; but in all probability this was no new suggestion. Ambrose Paré, in his book on Surgery, published in Paris in 1579, translated into English in 1649, suggests that the cavity should be covered over by a gold or silver plate, “made like unto a dish in figure, and on the upper side which shall be towards the brain, a little sponge must be fastened, which when it is moistened with the moisture distilling from the brain will become swollen and puffed, so that it will fill the concavity of the palate, that the artificial palate cannot fall down, but stand fast and firm, as if it stood of itself.” A modification of this was suggested shortly after by Isaac Guillemeau, who, to increase the accurate adaptation of the obturator, proposed a “packing” of sponge or lint around the edges of the apparatus. At the beginning of the eighteenth century, Garangeot, in his ‘Treatise on Instruments,’ proposed to fix the sponge, which was placed above the obturator in the nose, by passing through it a screw stem, arising from the upper surface of the plate, and screwing a nut down upon it; evidently trouble had arisen in some cases from the nasal sponge becoming liberated, and retained in the nose.
In this country, Wiseman, Sergeant-Surgeon to King Charles II, suggested the accurate filling of the cleft with a paste composed of myrrh, sandarac, and a number of other ingredients; but as to the means by which this was to be maintained in position we are left in ignorance.
The discontinuance of the nasal sponge seems to have first occurred to Astruc, who, in his ‘Treatise on Syphilis’ (1754), replaces it by a silver button attached to the upper surface of the obturator in order to avoid the unpleasantness arising from the absorption of mucus. This was soon followed by another suggestion emanating from M. Pierre Fouchard (1786), who describes a silver obturator with an arrangement of metallic wings, worked into position after introduction through the opening by means of a hollow stem and nut, which, when screwed down, kept the wings covered with soft sponge across the aperture. The introduction of “elastic gum” as a suitable substance to be used in the restoration of the velum and uvula was the next step in advance; this was utilised in 1820 by M. De la Barre, who devised some very clever, but extremely complicated pieces of mechanism. Thus far it appears that no particular precautions had been taken to secure the accurate fitting of the apparatus; but in 1828 Snell drew attention to the necessity of obtaining an accurate model of the mouth, and his results, in consequence, were much more satisfactory. Since that period various instruments have been devised and used with more or less success; but in this work it is unnecessary to do more than mention the names of Stearns, Kingsley, Sercombe, Ramsay, Oakley Coles, and Wolff as being authorities on the subject, and to indicate some of the plans adopted.
The obturators employed in recent days have been much simplified, and practically have been reduced to a simple plate fixed in the roof of the mouth by an arrangement similar to that employed for ordinary dental plates, i. e. attached to one or more of the teeth. This is a great improvement on the old form of “plug” obturator, which by its constant pressure had the effect of increasing the size of the opening.