The following technique is that recommended by Shepherd: Chloroform is the best The child should be wrapped in a sheet or large towel, so that the arms may be confined, and then held in the arms of a strong nurse. Sitting in front of the patient, the oper ator should first cut through the mucous membrane attaching the lip to the gum, and freely separate it so that the lips hang loosely. The edges of the cleft are then freely pared by using a narrow bladed knife and transfixing the edge of the cleft well up to the nostril; the flap is cut free above, but below it is left on each side attached to the edge. As the two edges of the cleft are seldom the same length, one being usually distinctly longer than the other, on the longer side the soft parts should be more freely freshened. Both flaps should be cut as far as the red line of the lips. Any redundancy can be cut off without any trouble. The flaps should not be sep arated from the edges of the cleft be low until several sutures have been placed in the lip above and the fastened edges of the cleft accurately adjusted near the nose. The paring from the shorter side is then cut away, and more or less, as occasion requires, of the tis sue at the red portion of the lip removed; the flap of the long side is brought over as before, and adjusted as accurately as possible. During the operation an as sistant compresses the sides of the cleft with his fingers. Should any blood get into the mouth, it must be at once re moved with sponges on handles. Silk worm-gut and horse-hair sutures are employed. Care should be taken not to go through the lip while suturing, but to dip down to the mucous membrane only; the stitches should range on each side at least one-eighth of an inch from the edge. If the sutures have not been satisfactorily placed or seem to pull too much, or if there is a slight unevenness, one should immediately take them out and reintroduce them. After the main sutures of silk-woim gut are placed, in termediate ones of horse-hair may be employed, and afterward the lip everted, and the mucous membrane sutured in the mouth. He states that the most im portant points to be observed in the operation are: 1. Freeing the lip from the gum. 2. A free sacrifice of the edge of the cleft. 3. Accurate apposition of the parts.
In dressing, an antiseptic paint (iodo form, resin, oil, and alcohol) applied over a piece of lint or cotton is used. If the usual cheek-straps are applied to preserve tension, they should be made of diachylon plaster, and the cheek parts cut broader than the part running across the lip; they should interlace in the middle line, the cheeks being well pulled forward.
Zinc-paste dressing for harelip recom mended as superior to others as to sim plicity, convenience, and mechanical and antiseptic effects. This paste, first de scribed by Socin in 1613, consists of zinc oxide, 50 parts; zinc chloride, 5 to 6 parts; water, 50 parts. After complet ing the operation, the suture-line is dis infected and carefully dried. The paste, freshly prepared, is applied over the whole upper lip with a brush or spatula, with one or two very thin layers of cot ton for support. If the wound extends into the nostril, the paste should cover it throughout its extent, but without blocking the nostril. It. dries rapidly and forms an air-tight, firmly-adherent covering, over which the nasal secre tions run without dissolving it. It is non-irritating. The dressing is changed on the fourth to sixth day for removal of sutures. If not already loose, it. can be slowly cut away with scissors. A fresh dressing is then applied, which is allowed to remain till separated spon taneously. Van Noorden (Befit. zur. klin. Chir., B. 4, H. 2, '99).
Before operation it is very important to know that the child has not been ex posed to any fevers, measles, or tina. This is the one cause of failure.
Another is the inordinate crying of the child, and also the too-early removal of the stitches. Sepsis is the great cause of failure; sutures should not be re moved too soon. Silk-worm gut is left
in from six to ten days. Should primary union not occur, one should wait until the inflammatory action has subsided, and then freshen the edges and bring them together. After the operation there is often great difficulty in breath ing through the nostrils, and rubber tubes introduced are often a great aid and prevent collapse of the nostrils.
It is advantageous to introduce a prophylactic suture before the freshen ing of the edges of the cleft is begun, so that the moment the dissection is ended the raw surfaces are brought in confrontation and the bleeding com pletely suppressed. Carl Beck (Med. Monats., Apr. 3, '90).
Important points in the treatment of harelip include the following considera tions: 1. Harelip babies are not neces sarily feeble at birth, and by proper feeding can he kept up to the normal standard. 2. The field should be kept clean with aseptic washes before the operation. 3. One should operate in the sixth to the eighth week. 4. One should not slash with scissors, but cut and trim carefully with a knife. 5. The upper lip should be freed thoroughly from the jaw. 6. The nares should be anchored with shotted wire. 7. No pins or heavy outside sutures are to be used. 8. Cr4e lisse, not surgeon's plaster, is to be used. 9. The heavy inside stitches are to be left for six days. 10. After operation special attention should be given to the care of the bowels and to proper feeding, as on this very often hangs the whole success of the opera tion. Mumford (Boston Med. and Surg. Jour., Mar. 3, '93).
In double harelip, when there is no projecting intermaxillary process, all the mucous membrane from the central por tion is cut away and the flaps taken from the sides of the cleft as in single harelip; the central portion is sutured on each side to the lateral clefts, and the lateral flaps run across to meet each other below the central portion, the lower part of which is freshened. What is in excess is cut away. Sometimes the central por tion may be cut into the shape of a V and the lateral flaps adjusted to it. Where the intermaxillary bone projects the case is more difficult. In some cases, such as where the bone grows from the tip of the nose, it must be sacrificed, but it can be broken back and forced into the cleft. Sometimes it is necessary to pare the edges of the gums, and in some cases the bone is kept in position with wire or silk sutures. One should always try and save the intermaxillary bone.
In double harelip, where the pro labium has to be utilized as a column for the nose, the case resolves itself into one of single harelip with a very wide cleft. But where the prolabium can be utilized in the lip, it is pared on its three sides (all the red being removed) and inserted between the apposed sides of the cleft, its lower border being united to the upper surface of the flap as the latter passes beneath it to reach the notch prepared for it on the opposite side of the lip. C. H. Golding-Bird (Brit. Med. Jour., Oct. 25, '90).
When necessary, the entrance of blood into the air-passages may be prevented by placing the child in the Trendelen burg position, or holding it upright with the head inclined forward. The effects of hemorrhage and shock may be com bated with subcutaneous injections of large quantities of normal salt solution.
Hypertrophy of the Lips. — Undue thickness of one or both lips is occasion ally observed in healthy individuals, but more frequently in strumous children. When the hypertrophy is sufficiently marked to disfigure the patient, opera tive procedures must be resorted to. The deformity is usually corrected by remov ing an elliptical piece of the mucous membrane and submucous tissue in a horizontal direction. The edges readily heal together. The tissue removed should represent the excess only, removal of an excessive mass being followed by disfig urement due to undue recession.