A course of Cystogen-Lithia is indicated Wherever Uric Acid is a possible Etiological Factor. is an effervescent tablet containing Cystogen and Lithium Tar- Samples and Literature on Request CYSTOGEN CHEMICAL CO. He Has TWO GOOD LEGS One Made by Nature READ WHAT HE SAYS: To A. A. MARKS, N. Y.: I wish you to know how many days the leg you made for me worked during the year. During the month of January I worked 407 hours; February, 292; March, 358; April, 253; May, 280; June, 316; July, 337; August, 376; September, 337; October, 391; November, 375; December, 337. If you will add up the number of hours you will find it amounts to 4,131, or more than 413 days for the year, and you know there are only 313 working days in the year, so I have worked a year and one hundred days in the year, wearing your artificial leg every hour of that time, and it has not cost me one cent for repairs. It is as good now as it ever was. The engine that I am firing is one of those big ones thathauls coal from the mines to The Other by Marks Pottsville, No. 148. I enclose a photograph of my engine, where you will see me at my post of duty. I get all over her with the same ease that I ever did. Sometimes I climb on top of the boiler when in motion. I can tell you more about what I am doing with my leg if you want it. The hard use I am giving your leg, and the excellent wear it is giving, proves it to be the best in the world. I am respectfully yours, FRANK FAUST, Pottsville, Pa. This demonstrates that the loss of a leg does not debar a man from firing a locomotive. Manual of Artificial Limbs and Measuring Sheet sent gratis. Address A. A. MARKS, 696 to 702 Broadway, New York Vol. XXXVII. Incorporating The Kansas City Medical Index-Lancet An Independent Monthly Magazine MARCH, 1918 Original Contributions [EXCLUSIVELY FOR THE MEDICAL HERALD.] A FEW PRINCIPLES OF HARELIP AND CLEFT PALATE PROCEDURE* WILLIAM L. SHEARER, M. D., D. D. S., Omaha, Neb. When we come to consider surgical procedure in harelip and cleft palate, one most important fact presents itself for serious thought, i. e., the babe does not have a voice in the choosing of the one to serve him. All that is given him is a cry and it is this cry which should be respected. A most deplorable picture is placed before our eyes. With this thought in mind I shall endeavor to outline a few steps of the work which are necessary to accomplish the best results. There seems to be a misunderstanding relative to the time for surgical intervention in the different phases of this class of surgery, therefore it is advisable to give the experience of men devoting their time largely to this field. Brophy has outlined this most clearly in his late work and his conclusions are corroborated by many surgeons. If the babe is presented with cleft palate involving the alveolar border of the maxillary bones this operation should be done first. To accomplish the best results it should be performed from the age of ten days to six or eight weeks. It should be treated in the same manner as an ununited fracture. The lip and soft palate should not be considered until there is bone union. It should be done early because the bones at this time are comparatively easily moved into place and because the nervous mechanism of the babe at this age is so slightly developed that little shock follows. It is advisable to repeat that the first undertaking should be the closure of the cleft of the bones because herein lies the future success of the subsequent operations. The important steps in this operation are as follows: The silver wires are gently passed through the malar bone just under the floor of the orbit on either side. In so doing should a tooth follicle be encountered, the surgeon's tactile sense will Read before the Medical Society of Missouri Valley at Lincoln, Neb., Sept. 21, 1917. No. 3 immediately direct him around this obstacle so that rarely will damage to the tooth follicle occur if care is exercised. These sutures are passed into the bone tissue just about where the mucosa folds upon itself. Lead plates which act as splints are placed along the buccal. The bones are placed in their normal relationship to each other by the pressure of the thumbs. In this way the silver wire and lead plates act only as supports and are not employed in forcing the maxillary plates together. After this is accomplished it is necessary to dissect the mucosa from the ends of the maxillary bones so that bone tissue will meet bone tissue and will thereby result in bone union. Normally the upper arch is smaller than the lower arch. If careful observations are taken of a child with cleft of the malar bones, it will be found that the lower arch fits just inside of the upper arch. When this first operation is completed the transformation is as follows: The ridge of the lower arch will be found to just overlap the ridge of the upper arch. In single cleft of the malar bones the nose will be found decidedly to the left or the right, as the case may be, of the median line. This first operation does not only bring the arches into position as above described, but also places the nose in a position where, if a line were drawn from the middle of the forehead to the center of the tip of the chin, bisecting the face, it would pass down over the center ridge of the nose. This will be illustrated with lantern slides to follow, also the technique. The next operation should be done after the bone union, at any time the condition of the child will justify. This involves the lip and making of the nostril. One of the most important surgical procedures is that necessary in the correction of the harelip. Indeed, so important from the standpoint of cosmetics that I shall not endeavor to outline the steps in this paper, as they will also be definitely outlined with the lantern. The next operation, which will be upon the soft palate, should not be undertaken earlier than from the fourteenth to the twentieth month, or about the time the child endeavors to speak. The closure of the cleft of the soft palate is by no means the most important part of this procedure. The tissues must be placed in their proper positions so that the normal function will be, insofar as possible, given to the individual. It must be borne in mind, in this branch of surgery, that unless the speech, etc., are materially benefited, even though the cleft is closed, the operation is largely a failure. Certain definite steps must be carefully carried out to give the child that flexibility and resiliency of the palate so much needed in speech. A specially designed periosteal elevator should be used to perfectly separate the soft tissue from its periosteal attachment. Great care is necessary in the very initial step of passing through the muscular mucosa down to the periosteum in the process of lifting the soft tissue. It should be freed all along the posterior border of the horizontal plates of the palate bones, extending down over the hamular process on either side. Very rarely is this accomplished in cleft palate procedure. When the horse-hair coaptation sutures are placed, no tension can be allowed, or sloughing will follow and the operation result in failure. It is necessary at this time to place tension sutures of silver wire supported by lead plates to prevent tension on the horse-hair sutures as described above. In this operation, post operative care is most essential. Isolation of bacteria being impossible it is necessary to carefully irrigate the parts after each feeding, and in some cases a half dozen times a day. When it is impossible to isolate an organism it must be combatted by other means, and in this instance constant irrigation is considered one of the laws of success. In the last two operations, namely, the lip and nostril, and the soft palate, great care should be exercised not to traumatize the tissue more than is necessary, as sloughing, particularly in the soft palate, is apt to follow. Lateral incisions in the soft palate should never be made because in so doing the tensor palati muscle and nerve are very likely to be severed, and once severed do not reunite. Following in the wake of this unfortunate procedure is deafness, owing to the fact that by traction in the act of swallowing and speaking the tensor palati muscle dilates the pharyngeal orifice of the eustachian tube. Permanent sutures left in the mouth at the completion of any of these three operations should be silver wire, lead plates and horse-hair, for the reason that they do not absorb the saliva which is constantly contaminated with different forms of bacterial life. It has not been the intention of the writer by any means to outline all of the steps in these three operations-only to give a general summary of the more important steps to insure success in this field of surgery. Nor does he claim any originality here; on the contrary he cannot consider the subject in hand without acknowledging with sincere gratitude and appreciation his friend and teacher, Dr. Truman W. Brophy. whose achievements in original research, and whose lofty ideals have been a constant inspira tion. |