sions, if it is definitely asked what is the cause of this division of the lips, it is seen that it must be sought for in the evolutions of the fœtus at the different ages of the intra-uterine existence. The force of growth which presides at the disposition of parts, at their juxtau, position, at their reunion, interrupted in its efforts, ceases to act, and the lips formed from three points of increase, one median and two lateral, which this force incites to fusion, remain separated, so as to resemble the lip of the hare. When the reunion does not take place at all, the hare lip is double; when it takes place between two of these points only, the median and a lateral, the hare lip is single and is only observed on one side of the mouth. M. Velpeau and M. Cruveilhier do not admit this theory of the formation of hare lip, by an arrest of the primary force charged with the formation of the tissues. They believe that hare lip is simply the result of an intra-uterine disease of the lips which leads to the division of these parts. Congenital hare lip presents several anatomical forms. Firstly, the division is always situated at the upper lip. There are only two exceptions to this rule reported by Christopher Seliger and Nicati. It usually only involves the lips: this is simple hare lip; the division is either single and lateral, or else it is double. In the first case the division exists below the right or left nostril; in the second there is below each nostril a fissure separated by a cutaneous tubercle. In other cases the fissure of the lips is accompanied by fissure of the maxillary bones and division of the arch of the palate; this is what is termed complicated hare lip. 1. The labial hare lip is either complete or incomplete. The fissure extends to a greater or less height even into the nostril. When the division is single, it is always lateral, and forms a considerable separation, gaping below, the rounded angles of which are drawn by the muscles of the lip and allow the teeth and gums to be seen. The lips are very frequently atrophied, but without real loss of substance, although the contrary opinion was for a long time maintained. When the hare lip is double, but always only involving the lip, this is divided into three portions, a median and two lateral. There are two fissures which descend from each nostril, and which are separated by a median tubercle, more or less large, and depressed. The deformity is well represented by the shape of the letter Y. One of the children on whom I operated at the Necker Hospital, presented this form. The edges of the buccal fissure are rounded off and atrophied. The nose is sometimes flattened and deformed when the fissure extends as far as the nostril. The simple hare lip, single and double, lasts as long as the individuals live, and leads, in time, to the deformity of the maxillary bone, which becomes flattened and allows the p ection of the incisor teeth in front. 2. The complicated congenital hare lip may be single or double like the preceding. There may also exist at the same time as the labial fissure, a fissure of one of the alæ of the nose, separation of the palatine plate, either in front only or in its whole extent; separation of the plate of the palate, and of the velum of the palate; an acquired or congenital projection of the bones on which the diseased lip rests, and of the median tubercle; lastly, absence of the palatine plate and of these. os vomer. The most usual complication, and that which the surgeon may alleviate, is the following. The fissure of the lip may also extend to the maxillary bone. It is a separation on one side of the maxillary bone; if the same is repeated on the other side, the two divisions represent au aba a V, the opening of which is directed forwards, and the angle corresponds to the anterior palatine foramen. These two divisions sometimes are Luce & united into one only, which traverses the median line. The hard portion of the palate is then separated into two halves as far as the velum, which may itself be separated into two portions. The mouth then communicates with the nasal fossæ by an opening which extends from the lips to the pharynx. Sometimes the clefts coalesce in front, and the median tubercle is wanting; it is in this which constitutes Kusur " wolf mouth. Labial hare lip is attended with the inconvenience of impeding the Contin pronunciation, and hindering the articulation of those consonants called explosive—the b, and the p, the v, the f, and the m, &c.; it has also cle TREATMENT. h The treatment of hare lip consists in a surgical operation, which is easily performed. Dionis, Garengeot, Boyer, and Sanson, were of C opinion that hare lip should not be interfered with before the age of six or seven years; others recommend that it should be operated on a little more early; and, lastly, some, amongst whom may be found Busch, M. Bonfils, and, more recently, M. Paul Dubois, recommend the operation to be practised as soon as possible, even from the first or second day after birth. In a very interesting essay, M. Dubois* has decided this practical question with the consummate judgment which is observed in all his works. He has demonstrated, by facts, that the operation is not more to be feared when performed at this * Mémoire sur le bec-de-lièvre et le moment le plus opportun pour l'opérer. Bull. de l'Acad. de Méd. Paris, 1845; t. x, p. 760. age than at a more advanced period, and that then also the deformity of hare lip is more easily remedied. As the operation only diminishes, without preventing, the movements of suction necessary for nourishment, many surgeons are now agreed to operate immediately after birth. Up to the present time the immediate operation for hare lip has scarcely ever been performed, except in cases of hare lip without complication. Should it be the same in the cases of complication? Yes, certainly. Thus, MM. Danyau and P. Dubois have succeeded in a case in which there was a simple hair lip with fissure of the anterior half of the plate of the palate. A physician of the Oise, M. Boudon, was also successful in a case of double congenital hare lip with deep fissure of the palatine plate, which rendered sucking impossible. It was exceedingly difficult to make the child drink ¿¿ from the spoon; the liquids were, in a great measure, rejected out The of the lips. The child was only some days old when it was brought A to M. Boudon, and it was operated on four days after birth. hone edges of the labial fissure having been made raw by an incision, were united by the twisted suture. The first threads were removed at the end of twenty-four hours, and replaced by other threads less tight than the first. This dressing was renewed every day until the removal of the pins, so that the constriction was gradually diminished. The pins were not withdrawn until the cicatrix appeared rather firm. The operation did not cause any bad symptoms, and was crowned with complete success. One of my friends, M. Guiet, has also succeeded in a much more severe case in a child afflicted with double hare lip, and complicated on one side by the entire fissure of the hard and soft palate. The operation was not performed until the twentieth day; it was necessary to have recourse to it twice, in consequence of the detachment of one of the sutures, and yet the hard palate is united, and the neighbouring part of the velum palati to a small extent. Consequently it is my opinion that we should not hesitate; whether simple or double, complicated or not, hare lip should be operated on in the twenty-four hours which follow birth. Operation. When it is decided on operating after birth, it is proper to prevent the children from sleeping a sufficiently long time previous to the operation, so that immediately afterwards they may fall asleep. The operation consists of two stages, the paring and the reunion. The paring is done with scissors, in the following manner. The operator, placed opposite the child, sits in front of an assistant who holds the head, pressing the cheeks forward, so as to compress the facial arteries on the inferior maxillary bone in front of the masseters. He seizes the angle of the division of the lips with hooked forceps, then with one cut of the scissors he at once removes the red edge of the solution of continuity from below upwards, as far as the superior angle. The same is done on the opposite side, care being taken that the first incision is met. He thus removes a double angular flap which makes raw the edges of the hare lip fissure. Care should be taken to excise just upon the point of reunion of the skin, with the red edge of the solution of continuity. As soon as the paring is finished, the surgeon should reunite the edges of the wound as completely as possible. It is done by means of pins and thread, The first pin, either an ordinary or a special one, should be placed at the base of the division, near to the free edge of the lips. It should pierce at least a quarter of an inch of the pared border, and, directed obliquely, should protrude near to the mucous membrane; then, entering the opposite side, on the edge of the mucous membrane, it should appear on the skin about a quarter of an inch distant from the edge of the fissure. A piece-thread is placed A piece-thread is placed on these two ends of the pin and given in charge to an assistant. The second pin should be placed immediately below the superior angle of the wound, and if a third pin seems necessary, it is placed between the two others. The pins should be applied in a parallel direction. When the needles or the pins are applied, the thread is put on so as to embrace each needle and to make upon each a twisted suture. The thread should pass from one needle to the other, so as to allow all the wound to be covered. The thread is then fastened to the upper pin; the head and point of these pins are then removed with the scissors. The threads should not be drawn too tight, but it is necessary that they should keep the edges of the wound closely applied. Some surgeons apply the pins by piercing perpendicularly the entire thickness of the lip, so as not to leave a foreign body in the tissue to be united. This is a modification which may be useful. Others place a thread on each pin, so as to isolate each suture. I always operate in this manner. After the operation, some persons direct a bandage to be applied round the head, so as to confine on the cheeks a pad intended to compress them and push them forwards. This means, useful at a No bandage more advanced age, is rather injurious in the infant. should be applied, and the parts should be as the twisted suture leaves them. However, I advise, the separation of the wound should be prevented by the following means: on each cheek should be applied a square piece of linen, the anterior border of which is pierced for threads, those from one side passing into those of the other, they cross over the lips between the needles, and their ends are fixed to the child's cap. The child should be watched night and day, and they should avoid ah one. age than at a more advanced period, and that then also the deformity of hare lip is more easily remedied. As the operation only diminishes, without preventing, the movements of suction necessary for nourishment, many surgeons are now agreed to operate immediately after birth. Up to the present time the immediate operation for hare lip has scarcely ever been performed, except in cases of hare lip without complication. Should it be the same in the cases of complication? Yes, certainly. Thus, MM. Danyau and P. Dubois have succeeded in a case in which there was a simple hair lip with fissure of the hia anterior half of the plate of the palate. A physician of the Oise, M. Boudon, was also successful in a case of double congenital hare Tivu lip with deep fissure of the palatine plate, which rendered sucking impossible. It was exceedingly difficult to make the child drink hould from the spoon; the liquids were, in a great measure, rejected out of the lips. The child was only some days old when it was brought edine to M. Boudon, and it was operated on four days after birth. The edges of the labial fissure having been made raw by an incision, were united by the twisted suture. The first threads were removed at the end of twenty-four hours, and replaced by other threads less tight than the first. This dressing was renewed every day until the removal of the pins, so that the constriction was gradually diminished. The pins were not withdrawn until the cicatrix appeared rather fire The operation did not cause any bad symptoms, and was cro with complete success. One of my friends, M. Guiet, has also s in a much more severe case in a child afflicted with doub! and complicated on one side by the entire fissure of + soft palate. The operation was not performed until the it was necessary to have recourse to it twice, in c detachment of one of the sutures, and yet the hard the neighbouring part of the velum palati to Consequently it is my opinion that we shon' simple or double, complicated or not, hare " the twenty-four hours which follow birth. Operation. When it is decided on o to prevent the children from sleepin to the operation, so that immediat The operation consists of two st paring is done with scissors, in placed opposite the child, sit head, pressing the cheeks fo on the inferior maxillary 2151614 He seizes the angle then with one cut of |