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are now performed, the use of these has not been entirely superseded,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.
Artificial vela are always somewhat complicated, and that success will
attend their use cannot be assured. They consist of a vulcanite or gold
palate plate fastened to some of the teeth, and of a moveable flap
attached to it by a hinge and spring of suitable strength (Figs. 72 and
73), or simply of a rubber flap sewn to the posterior margin of the plate
(Fig. 74). These vela either rest above the palatal segments, or their
sides can be grooved to allow the palatal segments to fit into them. It
is very difficult to obtain an artificial velum sufficiently strong to
retain its position, and yet light enough to allow of its being easily
moved by the displaced and probably weakened muscles.
[Illustration: FIGS. 72 AND 73.—Figures of artificial velum as seen from
below and above, consisting of a metal palate plate with a velum hinged
to it, and supported above by a spring of suitable strength. (_Coles._)]
[Illustration: FIG. 74.—Another form of artificial velum. (_Coles._)]
In 1864 Dr. N. W. Kingsley, of America, suggested for this purpose the
use of soft india rubber of such delicacy as to resemble the normal
velum as nearly as possible. The rubber was arranged in two layers, one
of which rested above and behind the cleft, and the other overlapped for
about half an inch all the margins of the cleft seen from the front. This
amount of overlapping was found sufficient to prevent the apparatus from
becoming displaced during muscular contraction, and at the same time by
its means allowed the palate muscles to effect closure of the posterior
nares.
Mr. Baker, in the ‘Boston Medical and Surgical Journal,’[99] describes
a velum consisting of rubber distended with water, which was fixed with
a hinge to the back of the palatal plate, and under the control of the
muscles by being inserted above them on either side. A stop prevents it
falling too low, and the posterior extremity is almost semicircular to
allow of perfect apposition with the pharyngeal wall, which is drawn
forward by the superior constrictor. He claims to have met with much
success.
Wolff and Schiltsky have devised a similar apparatus, but use air instead
of water for distending the hollow rubber velum.
* * * * *
The main arguments that have been educed in favour of the use of
artificial substitutes for the palate rest upon the fact that until
recently the results of operative interference in severe cases of
fissured palate were often very unsatisfactory; in most, if not all, an
aperture was left anteriorly, which caused the speech of the patient
to remain indistinct. But with the greater success which has followed
increased experience and practice, this cause can be eliminated; and,
moreover, secondary operations for the attainment of this object can
always be undertaken with every prospect of success. Another objection
raised to operation is that no immediate improvement takes place in the
power of clear articulation; and although this is perfectly true, the
patient is in the same condition in this respect as when first provided
with an obturator, and will require the same educational process for the
improvement of speech. Again, the mental effect on patients operated
on is much more satisfactory than that following the application of
artificial assistance; whilst the presence of a foreign body in the mouth
is a source of continual danger and irritation; for there is always
the possibility of the obturator slipping out of position and becoming
impacted in the pharynx or œsophagus. Irritation of the sides of the
cleft not uncommonly results from their use, and may end in ulceration
and even necrosis. When obturators and vela are removed from the mouth,
a spongy granulating surface is often seen, bleeding on the slightest
touch, and giving rise to a peculiar fœtor of the breath. Under these
circumstances a temporary discontinuance of the apparatus becomes
necessary, a most undesirable and unpleasant contingency.
Again these appliances cannot be fitted to a patient much before the age
of fifteen, and the habit of defective articulation has been fully formed
by that time. They also need constant renewal, and are thus a source of
continual expense, putting them beyond the reach of hospital patients.
In spite, therefore, of the optimistic arguments so boldly maintained
by our American dental confrères, and of the successes they claim
to have attained by the use of these artificial means, I am driven
to the conclusion that in the majority of cases of cleft palate
operative interference, followed by a suitable educational course, will
give results incomparably superior to these, and unattended by the
above-mentioned disadvantages.
But whilst strongly maintaining the superiority of the treatment by
operative rather than by mechanical means, I will readily grant the
greater applicability of the latter in certain conditions; viz. in
acquired defects of the palate, the results of syphilis, traumatism,
or surgical operations involving extensive loss of tissue—as, for
instance, after excision of the superior maxilla: obturators are almost
invariably the only means by which these apertures can be closed. In
cases of congenital cleft where the os incisivum has needed removal,
leaving a broad anterior opening the closure of which by operation is
often impossible (p. 135), the application of an obturator is similarly
advisable; and one suggests this method of treatment the more readily
from the ease with which it can be effected, inasmuch as it merely
necessitates an extension backwards of the plate which carries the
artificial incisors. The communication between nose and mouth is thus
effectually closed, and the functional success of previous plastic work
and subsequent educational efforts ensured.
In cases of hopeless deformity, where the palatal tissue is so attenuated
that operative interference is impracticable, the recourse to artificial
assistance is inevitable; but such cases are fortunately rare.