TREATMENT. — The method recom mended by Mr. Teale, of Leeds, is usu ally resorted to, and is performed as fol lows: "The everted lip is divided into three parts by two vertical incisions three-fourths of an inch long and carried down to the bone. These incisions are so planned that the middle portion be tween them occupies one-half the lip. From the inner end of each incision the knife is carried upward to a point one inch beyond the angle of the mouth. The two flaps thus marked out are freely and deeply dissected up. The lateral flaps are now raised and united by twisted sutures in the mesial line and supported, as on a base, by the middle flap, to which they are also attached by a few points of suture, leaving a triangular even surface to granulate." This operation usually gives good results, but it must some times be slightly modified to suit the ex isting conditions.
Excision of Labial Malignant Growths.—The operation is an easy one, a ''-incision, including all the mass and brought together with harelip-pins or deep sutures of silk-worm gut, constitut ing, as a rule, the only procedure re quired. The wound, properly dressed, usually heals in a week. When the growth has progressed further, all dis eased tissues — always including all enlarged glands — should be removed; the operation is necessarily more exten sive and perforce less promising. A plastic operation should be subsequently resorted to to form a new lip.
Fricke urges that every ulcerating wart about the lips which resists treat ment should be promptly extirpated under local anesthesia by means of a pair of scissors. When the growth has progressed beyond this stage, every ana tomically-related lymphatic gland which is placed in its typical position must be removed. If the glands are not per ceptibly enlarged, they are taken out with the surrounding fat. First the glands, then the tumor, is extirpated. This sequence is important. As a rule, the incision should be carried two-fifths of an inch wide of all obviously affected tissue. There were only 3 cases of local recurrence out of 113 operations in which this rule was followed.
When the edges of the new lip are de void of mucous membrane, the mucosa may sometimes be pulled over the defect from within and stitched to the skin. It should not be forgotten that a lip formed of skin alone, with no internal mucous covering, will shrink enormously when cicatrization takes place.
Macro stoma (Large Mouth).—This is a deformity of the mouth due to failure of the maxillary process to unite with the mandibular process during develop ment. As a result, the slit constituting the mouth is not central, and may be prolonged on the one side of the face so as almost to reach the ear. This con dition is often associated with malforma tion of the auricle.
TREATMENT.—The edges of the buc cal opening may be freshened and united, leaving enough of the aperture to constitute a normal mouth. The lat
ter must not be made too small, how ever, the patient having to undergo a gradual training in the use of the lips in speaking, drinking, etc. In some cases a plastic operation is required.
Cleft Palate.—This condition is the result of imperfect union, during foetal life, of the two horizontal septa which, by their growth, form the partition be tween the nasal cavities and the mouth. When the posterior portions of the proc esses fail to coalesce, the resulting tri angular slit forms the "cleft." The extent of the opening varies from a small slit merely separating the uvula into two halves (bifid uvula) to complete central division of the soft and hard palates. In many cases of the latter kind the margin of one of the lary processes is fused with the vomer.
It may also be associated with harelip on one or both sides, the intermaxillary portion, in the latter case, carrying two or three incisors.
The condition, as is well known, in terferes more or less with voice-produc tion. owing to the escape of air into the nasal cavities, and with deglutition, food being sometimes forced into the nasal space. During infancy this some represents a dangerous feature, the infant being unable to suck torily, owing to the inability of the soft palate to close off the naso-oral isthmus during deglutition.
TREATMENT.—The time at which op erative procedures should be resorted to depends upon the condition of the child, the extent of the deformity, and the de gree of interference with normal feed ing. In inextensive clefts the child soon adjust the soft tissues of the mouth to the existing malformation, and finally swallows sufficient food; but an early operation is indicated to avoid imperfect enunciation when he begins to speak. In England it is customary to operate about the fifth or sixth year; in America about the third.
When the child is strong and well nourished, an effort should be made at closing the palate long before the time laid down as proper by the majority of surgeons. Haemorrhage in these young children is always slight, and is easily arrested; the stripping of the mucous membrane, with its underlying perios teum, is easy; the vitality of the flaps is distinctly greater than at a more ad vanced age, and adhesions between the sutured surfaces is much more likely to take place. Debove (Lyon Mad., vol. lxx, '92).
When interference with deglutition is such as to prevent proper feeding of infants, Mansell - Moullin recommends that a flap be adjusted to the rubber nipple so disposed as to close the cleft when the child has it in his mouth, or if the nipple be long that the opening be on its under surface. The physio logical function of the soft palate is thus replaced and the child properly nour ished until the operation can be per formed.