The use of artery forceps is not advisable, because the blood supply of the badly nourished flaps may thereby be still further impaired by pressure necrosis.
3. The first and most impor tant part is the detachment of the soft parts from the superior max illary bone. They should be de tached and mobilized sufficiently to permit making the cleft disappear without tension. If this has been properly done, any further incisions or sutures to reduce tension are superfluous. T have never been obliged to resort to them in one hun dred and thirty-two cases, and would never do so because they cause a further disfigurement which is unnatural in a ocemetic operation.
4. The detachment of the vermilion border of the lip and the arrange ment of the incisions should as far as possible be sharp and straight. Badly nourished and pinched tissue particles imperil the suture. For the same reason manipulations and pinching with forceps should be avoided as far as possible with the thin skin at the edge of the lips; we prefer to use the fingers.
The freshened parts .should offer the broadest possible surfaces for suture.
5. The sutures should be as deep as possible, without, however, perforating the mucous membrane; they should never be drawn tight for fear of constriction and cutting through the skin. Ss soon as the external sutures, which in complete clefts should reach tvell into the nose, are tied, the mucous membrane is likewise to be sewn on the inside, because it is only by avoiding angles and pockets that accumula tion and decomposition of blood and of food particles, which imperil the healing, ran he averted.
0. The skin wound is painted with a resinous solution (see p. 4), over which a fine layer of gauze is placed; the Dares are plugged in order to prevent the nasal secretion, which is always infectious, from exuding.
7. On the first day no milk should be given, only tea, or saccharin tea, which is always followed by a little pure water. Milk is an excellent culture ground and the mouth cannot easily be cleansed. The mucous membrane has not agglutinated and is probably unable as yet to protect itself. Milk should not be given before the second day, and then always followed by water to wash it all away. The milk is administered through a medicine dropper or a sterilized rubber nipple which must have a large opening to admit of easy suction.
S. The resinous gauze bandage remains in place until the seventh day. In the meantime the wound is occasionally painted over again, until on the seventh day the sutures are carefully removed, the wound edges having now healed so firmly that their parting not be appre hended. Care should be taken to prevent children from sucking their
fingers by applying cuffs, stiff sleeves, etc., as otherwise they would tear the Wound open. The little patients are generally discharged on the eighth day.
These rules have been formulated in practice, clinically tested, and can be safely recommended. The mortality at our clinic has been reduced to 2.2 per cent., if all eases are included; omitting the eases of status thymicus and gast ro-intestinal catarrh (death occurring fourteen days after operation) the figure is only 0.74 per cent.
Secondary operations should not be carried out until several months later.
For operations on bilateral harelip I use Hagedorn's method exclusively (Figs. 12a and 12b, Plate 1, and Fig. 13).
The closure of the bilateral cleft is rendered difficult by the pro trusion of the intermaxillary hone, which usually oeeurs in these eases.
It is not advisable to unite the lip over a prominent bone, because it would easily give rise to a beak-like appearance of the upper lip and, besides, imperil the safety of the suture. In the most pronounced cases it is certainly best to remove the prominent intermaxillary bone and to use the skin flaps which correspond to the future philtrunt to cover the septum, as proposed by Lorenz. Owing to the removal of the inter maxillary bone the upper lip certainly will look flat and depressed, but this defect can be remedied by a dental bridge. At all events the practical result is better and the bridge teeth can be better used for mastication than those growing in the internmaxilla•y bone, which lacks in firmness or has been loosened by attempts at reposition; besides, these teeth rarely occupy a correct position.
The resection of the intermaxillary bone causes considerable hemor rhage which, however, can be controlled by inserting a suture around the wound. Other authors (Bardeleben, Blandin, Partsch) suggested a cuneiform excision from the vomer or linear intersection and reimposi tion of the vomer in such a way that the parts of the vomer will he shifted alongside each other. It has also been tried to effect in an orthopa•lic way a retrodisplacement of she intermaxillary bone before closing the cleft (Thicrsch, Simon). This, however, will not create normal condi tions, because the intermaxillary and superior maxillary bones will not unite, with the result that the teeth are defective both in position and direction. In eases of considerable deformity with protruding inter maxillary bone I consider the method of Lorenz advisable; lighter degrees correct themselves by the closed lip (Fig. 12b, Plate 1).