VOL. XXV.

APRIL, 1901.

No. 4.

Original Articles.

OPERATIONS FOR CLEFT PALATE AND HAIR LII'

BY DUDLEY P. ALLEN, A. M., M. D., CLEVELAND, O.,

Professor of Surgery, Medical Department Western Reserve University; Visiting Surgeon, Lakeside Hospital; Consulting Surgeon of Charity and City Hospitals, Cleveland, Ohio.

Some explanation is certainly due to the profession of such a city as Columbus, before undertaking to discuss before it the problems involved in operations upon cases of cleft palate and hair lip. To enumerate the steps by which the operation has reached its present position would certainly weary you beyond reason, and to name all of the operators whose suggestions have proved of value, would be needless before an audience of such high intelligence. My reason for considering the subject is that opinions expressed upon it vary so widely that it seems proper to place before you certain conclusions which claim for themselves nothing novel and contain no inventions of my own, but which represent a combination of various methods that have proved eminently successful in my hands, and may be confidently recommended to you. The success of the method is my excuse for addressing you upon this subject to-night. As an evidence of the success attained, I have brought with me a patient recently operated upon. I saw the patient when only five. months of age. There was a double hair lip with an unusually large anterior opening. The palate was widely cleft through its whole extent, both hard and soft. The inter-maxillary bone was carried upon the end of the nose, the bridge of the nose, the nasal septum and the inter-maxillary bone forming nearly a straight. line. The child was very delicate. At that time I advised simply an operation for uniting the hair lip, and as it was impossible to replace the inter-maxillary bone it was necessary to remove it. The portion of integument covering the inter-maxil

lary bone was so small that it did not begin to fill the gap between the portions of the lip on either side. Any attempt to draw it downward to its proper position in this cleft almost completely flattened the nose. It was, therefore, brought in between the two portions of the superior lip on either side, filling the gap to between one-third and one-half of its extent vertically. When drawn down any further than this it flattened out the nose very greatly, and the nasal cartilages by their elasticity. exercised great tension upon it. The defect was repaired as well as possible, however, and the child sent home, the parts having united. A second operation was advised as soon as the child was strong enough to endure it. Although arrangements for earlier operation have been made, the child was not finally brought for operation until January 24, 1901, when twelve years of age. At that time an operation was performed by the method which will be discussed later, and the indentation in the upper lip which had remained after the first operation was repaired. I think the result will be gratifying to all of you. I am speaking quite within bounds when I say that it was a case of very unusual difficulty, and so far as my personal experience is concerned the deformity was the greatest I have ever seen.

In discussing the subject before us many questions arise for consideration, and these will be presented in sequence as rapidly and as briefly as possible. The first question is as to the age at which patients shall be operated. Operations for hair lip are not usually dangerous. Unquestionably the earlier the defect is repaired the more opportunity there is for the parts to accommodate themselves in growth to their new location. For this reason it seems wise to operate at as early an age as possible. The age is not so much a question of months as of the patient's condition. Ordinarily patients with hair lip and cleft palate cannot nurse and must be raised by artificial feeding. They are usually very delicate. If operations are difficult they are badly borne. Ordinarily I feel that it is wise to wait until the child is from three to four months of age. The time of year, also, is worthy of consideration. Sometimes as a result of operations the child's digestion is seriously disturbed, and if this occurs during the summer season, it may lead to fatal results. It seems to me, therefore, wise to lay down two rules. First, the time of operation should be gauged by the patient's strength, it

being desirable that there should be a fair degree of resistance before undertaking the operation. This period is usually reached about the third or fourth month. Second, operations during the summer, when patients are especially liable to enteric troubles, should be avoided if possible. There are two special difficulties to be met in operations for hair lip, whether it exists alone or is associated with cleft palate. The first of these is the shortness of the upper lip, particularly in its central portion. Even if the lips be freshened and brought in apposition an indentation remains at the point of union. Should the lips be drawn together so that such an indentation does not exist at the close of the operation, it is liable to appear later should there be any retraction of the scar. To avoid this indentation it is desirable that the line of suture should be made to protrude a little at the time of the operation. This is done by a transverse in- . cision on either side, enabling one to lengthen the lip and draw it further downward by the approximation of the extremities of these opposing incisions. One very great aid, however, to overcoming the shortness of the lip is thoroughly to mobilize it by setting it free from its attachments near the alæ of the nose on either side. This is done after the edges of the lip have been freshened, by lifting the lip from the superior maxillary and cutting extensively upward and outward so that these portions of the lip and cheek are thoroughly separated from the bone, enabling the operator to draw the parts towards the center with ease. I know of no maneuvre which is of so great advantage in enabling one to bring the separated portions of the lip together in good apposition. Various suggestions have been made for holding the two portions of the lip together after they have been sutured and also as to the suture material. If sutures be well placed and the lip be well freed from its attachments on either side, there is little difficulty in retaining the parts in place. There is no better suture than silk-worm gut for the purpose. It is strong and non-absorbent and suppuration does not tend to follow it down into the tissues. For holding the upper portion of the incision, where there is considerable tension, a fairly strong suture is desirable. For the more inferior sutures a finer one is better. Ordinarily it is not necessary to place any sutures through the vermillion border of the lip. A suture may, however, be placed through the mucous membrane at the lower por