If the detachment has been successful and the cleft is not excessive it will be seen that the flaps have now become approximated. I have only in very rare cases been obliged to encroach upon the hamulus for purposes of mobilization.
Now follows the suture, for which I always use silk thread and ordinary highly curved needles. Many operators prefer wire sutures.
First suture the uvula, tie the sutures immediately, pull them for ward and unite the velum at the back as high as possible. Then the sutures follow in proper sequence from back to front. The most impor tant points are that the incisions be sharp, the sutures deep, and that the wound edges lie broadly against each other. The sutures should not engage the flaps broadly, nor should they be tied too firmly, in order to prevent defective nutrition of the flaps.
Paving closed the wound, I run two or three narrow bands from the lateral fissures around both flaps. They are tied rather firmly and the knot turned so that it can be placed in the nasal cavity. This pro cedure has been applied in our clinic with great success ever since 1902 to reinforce the sutures. Tamponading the lateral fissures is rendered superfluous by this method and in most cases it prevents congestion of secretions (fever, glandular swelling) (Fig.
For the first two days after operation the child is given a little tea and water and is kept as quiet as possible, taking care that there is no talking or crying. being a good culture medium, is not allowed before the third day, and then only diluted and followed with pure water.
Any other kind of mechanical cleansing is impractical in little children, while older ones should rinse the mouth with a 2 per cent. solution of peroxide of hydrogen. If necessary, the reinforcing bands are renewed on the seventh day with the aid of a large blunt ligature needle and the silk stitches removed. Any small fistulre will close well by drawing the holding bands tighter, and these are not removed until healing is effected. If the cleft is too large it will be necessary to close any remaining defects by flaps amputated from the lip, vomer, or cheek (v. Eiselsberg, Rotter, and Lane).
If the operation has been successful the palate will have a natural appearance. Deglutition will be facilitated, but speech generally remains defective. The velum be ing small and short, Passavant's ridge can be reached only with difficulty even if the velum muscles have remained intact. Gutz mann's linguistic exercises can now be com menced. Gutzmann has devised an elevator
which the can be raised, stretched, and massaged by the patient himself.
The linguistic exercises are especially directed toward the normal pronunciation of the palatal sounds, and in many eases are attended with excellent results. In cases where the lower margin of the velum is separated too widely from the posterior faucial wall, a lateral incision of the palatal arches in order to mobilize the wall, or a paraffin injection to enlarge Passavant's ridge, will help to correct this condition.
From this description it follows, as a matter of course, that it is in the interests of the patient to create normal conditions before the physio logical development of speech commences, the need for normal use of the organs of speech being greatest at that period.
For this reason I am unconditionally in favor of early operation, which means as early as the gtmral condition of the child shall permit; not before the end of the first and not, if possible, after the third year. Well-nourished children, front eighteen months to two years old and weighing from 24-30 pounds, bear the operation well. I have never been obliged to divide the operation into two parts (Wolff, Ilelbing), and in any case this means a twofold tormenting to the child, a twofold anxiety to the parents, and twofold danger from the anaesthesia. But I admit that with weak children this procedure may be considered in a given case.
In very wide clefts, or in eases where owing to a previous operativ( failure there is but little plastic material left, I have great hopes for the Preliminary approximation of the tipper maxillary halves from applying a suitable dento-orthoptrdic apparatus (endless screw). Ilelbing states that the parts may sometimes be approximated by more than I cm.
Large fistulae render necessary a second operation similar to the original one. Small fistuhe will close with the aid of holding bands or by application of caustics.
If the entire suture reopens, a new attempt at closure should be made not less than six months after the first operation.
Treatment by prosthesis and obturators (which has recently been again recommended by Suersen, Schiltzky and Warnecross) cannot replace operation. Obturators are expensive and must be frequently renewed during the period of growth and are generally disliked by patients. Children can only with difficulty resist the temptation of carrying the obturator in the pocket rather than in the mouth.