Of 132 cases 3 died, one of gastro-intestinal catarrh twelve days after operation, one of status thymicus a few days after operation, and one of bronchopneumonia and hydrocephalus three days after operation, so that at the most only one case, that dying of bronchopneumonia, can be attributed directly to the operation.
When should a child with harelip be operated upon? This depends much less on the age of the child than on its constitution and vitality. The experience gathered at our clinic has led us to formulate the fol lowing rules: The newborn and nurslings are operated upon in the first months of life but not until they have attained a weight of 3000 Gm. (0 lbs.). An exception is made if the deformity is so large as to imperil the child's life and the operation thus becomes urgent. Otherwise the mother is directed to suckle the child or, if this should prove impossible, to feed it with milk pumped from her breast until the required weight shall have been attained. Expectant treatment has the other advantage that children whose vitality is often questionable from concomitant anoma lies, such as congenital cardiac insufficiency, etc., are removed from the operation list by death. The first point to be observed is that nurslings should be in an otherwise normal state of health. Gastric and intestinal catarrh, affections of the respiratory tract, such as coryza or bronchitis, which frequently occur with harelip, jeopardize the final result.
Treatment. — The preparation for operation does not occasion much trouble. The buccal mucosa should not be exposed to the risk of injury by too energetic scrubbing with disinfecting fluids. All our cleansing consists in washing the face kith soap and water, rins ing and wiping the mouth with a light-rose colored solution of permanganate of potash.
The methods to he selected may be decided by a scrutiny of Plate 2. The French prefer the method of flap amputation of Malgaigne or 111i rank, German surgeons the cross suture and zigzag suture (Wolff, Hage do•n, KOnig). I have had the best results with Hagedorn's zigzag suture (Figs. 13 and 11, Plate 2, k, 1, in, p, q, r; see Figs. 11b, lOb, Plate 1), principally, I believe, because it adapts itself best to variations and because the cosmetic result can be controlled much better than in any of the other methods owing to the possibility of adjusting the skin margin and adapting the cuts to existing conditions. The seemingly
greater complexity admits of greater possibilities of variation, which in these very cases is of importance because there are hardly two harelips in a hundred that are quite identical and because there is hardly a cos metic error so disturbing as a permanent distortion of the mouth. The older methods I can only endorse for very slight cases, and even in these the practised operator will prefer the zigzag- suture.
The various phases are apparent from the illustrations.
Aside from the selection of the incision my experience has shown that weight should be attached to the following points: 1. Anesthesia is in my opinion unnecessary and dangerous.
Chloroform is too powerful a poison for the child's organism, espe cially for a prolonged operation, which is, in any case, a shock owing to the loss of blood. Prolonged ether amesthesia is not allowable owing to the danger of bronchitis. Young infants can be kept sufficiently still by wrapping them in a sheet and then being held between the knees by an assistant (Fig. 13). The blood is expectorated by the act of crying, while in tiniest hesia aspiration of the blood may easily occur, occluding the respiratory' tract and causing pneumonia. Operating the head hanging down considerably interferes with proper judgment of the facial contour, whose inverted appearance is unfamiliar; besides, this position increases hemorrhage.
Anesthesia is used only when children over One year old are operated upon; in these eases the remembrance and consciousness of localization forbids this painful proceeding without anesthesia.
2. Careful attention should be paid to the arrest of hemorrhage, little children being very suscepti ble to the loss of blood. The fingers of the assistant may compress the superior coronary artery. The application of small pieces of absorbent cotton, saturated with adrenalin, together with precision and rapidity on the part of the operator, will prevent excessive hemorrhage.