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 A LECTURE ON THE CAUSES AND TREATMENT OF HARE-LIP 
 
 DELIVERED IN THE POST-GRADUATE COURSE, 
 
 JUNE, 1898. 
 
 BY 
 
 FRANCIS J. SHEPHERD. M.D., CM., 
 
 Prolfssdr of .\iuiloiiiy, Mc(iill I'liiversity ; Surgeon to the Montreal General 
 
 Hospital. 
 
 Ri))rit\tv<} ffum the Montreal Medical Journal, ,Tanur<ry, IS!)!). 
 
'I'^Ji ■ 
 
 A LECTURE ON THE CAUSES AND TREATMENT OF HARE- 
 LIP DELIVERED IN THE POST-GRADUATE COURSE, 
 
 JUNE, 1898. 
 
 BY 
 
 Fbancis J. Shepherd, M.D., CM., 
 Professor of Anatomy, McGill University; Surgeon to the Montreal General 
 
 Hospital. 
 
 Gentlemen : — Before describing the treatment of the deformity 
 wbif'i I am to speak of to-night, I slionld like to give you a short 
 account of the development of the face, for all the congenital deformi- 
 ties met with are due to an arrest of this development at an early 
 period of fcetal life. A study of embryology is of great assistance to 
 the surgeon in enabling him to acc(junt for many of the congenital 
 conditions he not infrequently meets with. 
 
 Pr. ^toft.- Globular extremity of the medial nasal process. 
 3/.r.— Maxillaary arch. ^ 
 
 il/».— Mandibular arch. 
 //^.(/.— Hyoidean arch. 
 /<»*.— First branchial arch. 
 
 Development. — At a very early period of fo'tal life a series of clefts 
 (branchial) appear on the side of tlu; cephalic extremity, separated by 
 rods of tissue called branchial or (jill arches. The clefts conmiunicate 
 with the alimentary canal. The tir.st branchial cleft is between the 
 mandibular and hyoid arch(;s. The mandibular arch which is after- 
 wards developed largely into bone is divided into the superior 
 and inferior maxillary portions. The two sides of the inferior max- 
 illary portion early unite to form ^he lower jaw, but interposed 
 between the two superior maxillary portions is the fronto-nasal pro- 
 
coss. The space between the superior and inferior maxillary portions 
 is called the buccal cleft. This is closed early except where the aper- 
 ture remains for the mouth which is largci' or smaller according' as 
 the cleft is more (macrostoma) or less (microstoma) closed. Some- 
 times the buccal cleft remains open from (?ar to ear. Now as to the 
 nasal processes, these are divided into mes'ud and lateral ; the mesial 
 processes are united at their base by a depresseil median part the 
 frunto-nnsal pwccHS, but below they are separated and each ends in a 
 globular process (diagram ami slides exhibited). These nasal pro- 
 cesses, as development proceeds, extend backwards and along the 
 embryonic roof of the mouth forming the nasal laminte. Eventually, 
 the nasal processes coalesce in the middle line and form the intermax- 
 illary process and the middle part of the upper lip, the depression 
 between forms the septuu) of the nose and by a coalescence of the 
 nasal laminiB the rest of the nasal septum is formed. In rodents the 
 notch between the globular processes persists and there is a fissure 
 leading through the upper lip to the mc",;h Al)ove the depression is 
 a triangular space forming an angle with it, this forms the tip of the 
 nose and the triangular surface above it, the bridge. The lateral 
 nasal processes form the alfe nasi, these are not .so prominent as the 
 mesial. Between the lateral nasal processes and the maxillary pro- 
 cess the lachiynial groove passes from the eye to the nose. Where 
 the maxillary process of one side does not coale.sce with the globular 
 proce.ss then single hare-lip I'esults, and if the union fails in the bony 
 part as well, cleft palate is tlu'U .seen. When lioth maxillary proce.sses 
 fail to unite with the globidar |)roee.s.st's, double hare-lip results, in 
 this case the c'eft usually i^oes through the line of union between the 
 intermaxillaiy and superior maxillary Itone.s. The middle pai-t of the 
 lip thus floats free and has attached to it the two intermaxillary 
 bones, and is itself hanging from the septum of the no,se. A failure 
 of the two globular processes to unite is very rare though from time 
 to time cases are reported. The mesial or septal part of the nose is 
 developed from the junction of the globular processes. The septum 
 is at first broad and depresscl nvA the nostrils are widely separated) 
 as .seen in the lower races of mankind and monkeys. 
 
 The median union of the palate is completed about the 10th week 
 of f(etal life and the globular processes unite with the maxillary al.so 
 very early, the incisor foramen only remains to mark the junction of 
 the.se structures. The fact that the arrest of union oi these proce.sses 
 resuiL.T in hare-lip and that the union takes place ,so early, rather dis- 
 credits the a>anv stories one hears of hare lip find other deformities 
 being produceii by maternal im[)ressions. In many cases the ternlen- 
 
cies to such defonnitics runs in f;iniilios and it is not uncommon for 
 two chiMivn in one fVuiiily to sntti'V from liar(>-lip and clot't palate. 
 
 Havo-lip tlicn is a con^'enital affection and often is due to lieredity. 
 Tliei-e are vai'ious foi-ms of this deformity : 
 
 1. .Simplest, merely a notch in the red edge of the lip. 
 
 2. Throuoh the soft parts only and not <j;oin>j; throno'h to the nostril- 
 :i. The cleft throun^h the lip anu nostril and accompanied hy cleft 
 
 palate. 
 
 4. Double hari!-lip, with a floating intermaxillary bone and cleft 
 palate, occurs in ,',j of all cases. 
 
 , There art^ other i'oi'ms of deformity connected with ari'est of deve- 
 lopment of face, such as enlarij,ement of month, a persistence of the 
 lachrymal groove, kc. (Slides shown of these deformities.) 
 
 Single hare-lii) is usually on the left side, and is always to one side 
 in the line of the junction of the intermaxillary with the maxillary 
 bone. The child who sulfers from this deformity, as a rule, cannot 
 suck and has to )n' fi-d with a spoon. The niother's milk should he 
 drawn and used as food for the child. Some advocate injecting the 
 milk into the phaiynx with a glass .syringe, to which is attached a 
 piece of rubber tubing. Sometimes a stoppei-ed bottle with a large 
 teat, having the apei-ature below, is useful. Uul)bing the shild with 
 codliver oil oi- olive oil if it is puny, may help to keep ^'t in ccmdi- 
 ticn until old enough for operation. Artificial foods .should not be 
 fdven unless under dire necessity. The child should be k.^pt warm in 
 fiannel. 
 
 Best A(/e for Operation. — This depends on the condition of the child 
 and the character of the deformity ; should the deformity involve 
 only the soft parts and the child be healthy, operate at once for the 
 mother's sake and in order that the child may suckle. In simple 
 cases the earlitn- the opei-ation the better. The only danger in early 
 operations is from htsmorrhage, young children do not stand the loss 
 of blood well. On the other hand they soon make up lost blood. 
 Should the child be weakly, or the fissure l)e double and extend 
 through the hard parts, then the operation ought to be po-tponed 
 some weeks or even month.s. From six weeks to three months is 
 probably the proper time for operating. I prefer the age of six 
 weeks, this is well befor(> dentition has commenced. Some advise 
 waiting in the dilficult cases until the child is weaned, but this is 
 keeping a deforniity before; the family too long, ami furthermore it 
 renders the success of the operation nioi-e difficult. 
 
 Operatiov. The ninnl)er of operations devised for the relief of this 
 
 defovmity nre many and varied. The ingenuity of surgeons is taxed 
 
more by these plastic opei-ations than by any others, and tlie number 
 of methods is only equalled by the great variety of procedures advo- 
 cated by the gyna3Cologist m sewing up th(( abdominal wound. 
 Chloroform is the best anaesthetic in l \se cases. The child should 
 be wrapped in a sheet or large towel, so that the anus may be con- 
 fined, and than held in the arms of a strong nurse. A good light is 
 essential. Sitting in front of the patient, the operator should first 
 cut through the mucous membrane attaching the lip to the gum, and 
 freely separate it so that the lips hang loosely ; the edges of the cleft 
 are now freely pared by using a narrow-V)ladcd knife and ti'ansfixing 
 the edge of the cleft well up to the nostril, the flap is cut free above 
 but below it is left on each side attaclu'd to the edge. As the two 
 eib'es of the cleft are seldom the same length, one being usually dis- 
 tinctly longer than the other, on the longer side the soft parts should 
 be more freely freshened ; both Haps should be cut as fur as the red 
 line of the lips. Some advise cutting the flap of the shorter side quite 
 away and only leaving the long one, and then bringing this flapacro.ss 
 the middle line to fill the deficiency of the shorter side. Any I'cdun- 
 dancy can be cut off without trouble. It is my custom not to separate 
 the flaps from the edges of the cleft below until several sutures 
 have been placed in the lip above and the fastened (idges of the cleft 
 accurately adjusted near the nose. Now th(! paring from the shorter 
 aide is cut away and more or less, as occasion recjuires, of the tissue 
 at the red portion of the lip removed, the flap of the long side is 
 brought over as Ijefore and adjusted as accurately as possible. By 
 this means there is less hsemorrhage and no mistake of taking too 
 much or too little away is made, Of course, during the operation an 
 assistant compresses the sides of the cleft with his fingers, and thus 
 loss of blood is prevented. Should any blood get into the mouth it 
 must be at once removed with sponges on handles. Now as to 
 sutures : formerly wire and hare -lip pins were always used. At 
 present we employ nothing but silk- worm gut and horse hair. For 
 years I have used nothing else and with the best results. Care should 
 be taken not to go through the lip whilst suturing, but to dip down 
 to the mucous membrane only ; the stitches should range on each side 
 at least one-eighth of an inch from the edge. It has always been my 
 custom, if the sutures have not been satisfactorily placed or seem to 
 pull too much, or if perhaps there is a slight unevenncss, to immediately' 
 take them out and re-introduce them. A little painstaking at this 
 step of the operation is worth a good deal. After the; main sutures 
 of silkworm gut are placed, intermediate ones of horse hair may be 
 inployed, and afterwards the lip everted and the mucous membrane 
 
 i 
 
i 
 
 sutured in the mouth, by this means tlie continuity of tlie surface is 
 preserved amJ septic matter is prevented from enteriufj the wound 
 from the mouth. To recapitulate tlicn. The most important jioints 
 to Vi(! observed in the oj)eration ai-e : 
 
 1. Freeing tlie lip from the gum. 
 
 2. A free sacrifice of the edge of the cleft. 
 8. Accurate apposition of the parts. 
 
 The dressing should be simple. I usually apply an antiseptic paint 
 (made of ioiloform. resin, oil and alcohol) put on a piece of lint or 
 cotton and nothing more. If the usual cheek straps are applied to 
 pre.serve tension, they should be made of diachylon plaster, which is less 
 irritating than the rubber adhesive, and the checfk parts cut broader 
 than the pai't running acros.s the lip, they should intei-lace in the 
 middle line, the cheeks Ijeing well pulled forward. Before operation 
 it is very important to know that thi; child has not l)een exposed to 
 any fevei-s, as measles, or scai'latina. Thi.s is one cause of failure. 
 Another is the inordinate ciying of the child, and also the too early 
 I'einoval of the stitche.s. Sepsi.s, of couivse, i.s the great cause of failure 
 and this is most likely to occur in badly nourished infants with pool* 
 resisting powers. 
 
 It is very important that sutures should not be removed too soon. 
 In the old days of hare-lip pins they were removed in from 24 to 48 
 hours, because if left longer they would cut through the soft tissues 
 of the infant's lip. Now we commonly leave silkworm gut in from 
 6 to 10 days. Should primary union not occur, wait until the in- 
 flammatory action has subsided and then freshen the edges and bring 
 them together. Union now almost always occurs, because the parts 
 have become, so to speak, immune. After the operation the child 
 should be closely looked after. There is often great difficulty in 
 breathing through the nostrils owing to tension on the upper lip and 
 compression of the nostrils, and rubber tubes introduced are often a 
 great aid and prevents collapse of the nostrils. After a time the 
 parts get eased and the child will breathe easily through its nostrils. 
 
 The operation 1 have already described is that for single hare-lip. 
 Double hare-lip is less common and must be somewhat ditferently 
 dealt with. 
 
 Where there is no projecting intermaxillary process, the operation 
 is not difficult, 4or then all the mucous membrane from the central 
 portion is cut aw^ay and the flaps taken from the sides of the cleft as 
 in single hare-lip. The central portion is sutured on each side to the 
 lateral clefts and the .ral flaps run across to meet each other below 
 the central portion, the lower part of which is freshened. What is in 
 
excess is cut awny. Sometimes the central portion may be cut into 
 the shape of a V and the lateral ftaps adjusted to it. 
 
 In thos(! cases, however, where tlie intermaxillary hone projects the. 
 
 case is rendered umch more difficult. In some ca,ses, such as where 
 
 the Ixmo grows from the tip of the nose it mu.st he .sacriHced, hut 
 
 usually it can ho l)rol<en hack and forced into the cleft. Sometimes 
 
 it is necessary to pare the edges of the gums, and I have been obliged 
 
 in some cases to keep the bone in position with win! or silk sutur(>s, 
 
 It has been ol>jfcted that the incisor teeth which belong to this pre- 
 
 maxillary portion grow in crooked, if .so they can be afterwards 
 
 straight^'ued by a dentist, or the teeth may be pulled out. It is also 
 
 objected that the retention of the intermaxillary keeps open the palatal 
 
 cleft. Always try and save the intermaxillary l)one ami so prevent a 
 
 gap in the soH<l jaw. In cases where I have had to remove this bone, 
 
 however, there was remarkably little ileforndty. Sometimes there 
 
 >s a double hare-lip and only a single cleft in the bone. In such 
 
 cases th.! l)oi»y cleft of one side prcjccts and has to be forced back 
 
 with the thumb. In severe cases of operation in very weak infants 
 
 where much paring has to be done, and the bleeding is excessive, the 
 
 final stages of the operation may have to be postponed until recovery 
 
 from shock takes place. In very young children bleeding is a factor 
 
 which must be considered. (The different methods of operating were 
 
 then describe.l, such as Malgaigne's, Nelatons, Mirault's, Giralde's, 
 
 Hose's and many others. All were illustrated by lantern slides.)