PAPERS OX MEDICINE AND PUBLIC HEALTH 339 



The progressive surgeon no longer waits until a child 

 is from 3 to 12 years of age before operating, or after bad 

 habits of speech have been acquired, but now agreement 

 is fairly general as to the wisdom of early operations. 

 Closing the lip first, depending upon the traction of the 

 orbicularis oris muscle to approximate the bones, or | 

 ing a single wire through the anterior part of the separ- 

 ated maxillae and bringing them together thus, cannot 

 produce the best results. 



The closing of the lip and the resultant traction of the 

 orbicularis oris muscle will gradually move the anterior 

 part of the cleft bones into contact, but the bones will 

 not, as a rule, be normally approximated nor united. The 

 bone carrying the premaxillae protrudes beyond the 

 maxilla of the opposite side, leaving an ugly malforma- 

 tion of the nose and arch. Besides, there cannot be union 

 of the bones with the muco-periosteum intervening. They 

 only meet, remain malposed and leave the patient de- 

 formed throughout life. 



I have time here only to say, with regard to the pre- 

 maxillae, that they should always be preserved and util- 

 ized to maintain the normal dental arch, the facial con- 

 tour and the full complement of teeth. They should i 

 be excised, for an irreparable deformity is the unfailing 

 result. 



SPREADIXG OF THE TUBEROSITIES 



I have spoken of the closing of the lip first, as a means 

 of approximating the separated bones of the palate. 

 When the anterior part of the cleft is brought together 

 by the lip traction plan or by the single wire, the surgeon 

 fails to give consideration to the consequent separation 

 of the bones posteriorly. Every surgeon experienced in 

 this work realizes that oftentimes these bones are widely 

 separated posteriorly, due to the moving together of the 

 anterior part of the cleft and the action of the muscles ; 

 and they cannot assume a normal position unless meas- 

 ures are employed to overcome this separation. With 

 muscular force applied anteriorly and with no restrain- 

 ing force posteriorly, the maxillae act as levers, the malar 

 sses becoming the fulcra: and as the anterior ends 



