A low state of vitality may be due either to a general inherited weakness, or possibly to some associated deformity in another part of the body interfering with nutrition; or, again, simply to difficulties attending the administration of nourishment owing to the cleft lip and palate; for, as has been already pointed out, suction, and therefore breast-feeding, are impossible (p. 67). The problem that the surgeon has to solve lies in deciding to which of these causes the asthenic condition is mainly due, and whether the infant has sufficient strength to withstand the shock of the operation, and is in a state favorable for the occurrence of primary union. If due to some inherited weakness, or associated deformity elsewhere, immediate operation would be rash in the extreme, for the child is very likely to succumb. In any such case, careful hand-feeding is alone practicable; if a steady improvement is manifested, the operation may be undertaken later. But if, on the other hand, the asthenia is evidently due to the inability to take nourishment, the child gradually getting thinner and looking half starved (as I have seen in many cases), then the first opportunity should be taken of closing the lip, as such treatment holds out the only prospect of saving the child’s life. The greater the deformity, the more difficult will the question be to decide, for with the higher degrees of malformation the operation necessarily increases in severity. If associated with cleft palate this should be performed as early as possible, as the closure of the lip enables nourishment to be taken when administered in the way indicated above (p. 67). It would be well here to call attention to the fact that the early closure of the lip by the insensible and yet constant pressure brought to bear on the separated maxillæ has a most beneficial effect in narrowing the alveolar cleft. In my own experience I can testify to the decided diminution which has occurred in the width of many clefts when the lip had been closed by me some years previously, the patients having subsequently returned for operative treatment on the palate. Passavant[66] relates a case of a child whose harelip was closed at the age of nine weeks, and a year later the palate was found to be approximated without further operation, so that it merely presented a fissure. Some surgeons have attempted to gain a similar result by prolonged compression of the maxillæ. Trendelenburg,[67] on the other hand, casts doubt on this explanation of the narrowing of the palatal cleft, the existence of which he fully admits, stating he has seen the same occur in children who have not been operated on, and suggesting that it is due to the inward growth of the bones. Three different periods have been suggested for the operation, viz.: (_a_) The immediate operation—within two or three weeks of birth. (_b_) The early operation—from three weeks to six months. (_c_) The deferred operation—from six months to two years.