2nd. Freely to divide all false frena, and if the alar cartilage is misplaced, let the incisions separate it freely so that it may be fairly drawn into its proper place.

3rd. Never to attempt to close the lip so long as the intermaxillary bone is misplaced to any extent.

4th. To preserve and utilize all the parings. They are all wanted, as they all have their proper place; to this point I will revert at length.

5th. To use interrupted sutures, and discard all pins or needles as far as possible.

6th. To leave the line of union exposed, using no dressings or plasters for some days.

And now to justify these rules :

1. I never divide the true frenum. Its obvious use is to steady the lip, to prevent muscular action from drawing the centre of the lip away from its proper place. Let any one with his finger or tongue try on his own lip what the uses of the frenum are. The division of the frenum unsteadies the lip, makes it tend to run into a string, and, in many cases, leaves a permanent fistula into the nostril. It is, moreover, quite unnecessary, as the parts can be brought into perfect apposition without meddling with it.

2. I freely divide all adhesions or false frena, and I subcutaneously separate all the attachments of the ala nasi to the bone which interfere with the proper formation of the nostril. The advantages of this are so obvious that I need not dilate upon them.

3. Before paring the margins, the intermaxillary bone should be placed exactly in the centre, if not so already. Where there is fissure of the hard palate there is always this displacement. I generally manage this part of the operation by detaching the bone on the sound side by means of a narrow gouge. A strong forceps, with the blades protected with chamois leather, will then force the bone into position. As the nutrient vessels run along the mucous membrane, and chiefly on the inner surface, the gouge is the best instrument for loosening the bone. It may be used freely in this subcutaneous or submucous fashion; in fact, the more freely the bone is loosened the more easy is it to get it into position. The instrument has the advantage of being efficient and simple; no small recommendations now-adays.

4. I never throw away a particle of the parings. My incisions are made so as to make every fragment of them useful. On one side they are preserved to make the lip thick, and on the other to increase its depth. The method is somewhat complex, but a reference to Fig. 1 will make it intelligibie. When dealing with single hare-lip, I take the larger portion, that Fig. 1.

which includes the middle bit, and pare it freely from the nostril round the margin from a to b, until the point of the knife comes opposite the frenum. This incision goes through all the tissues of the lip except the mucous membrane. It follows the curved line of the margin of the fissure, and leaves & long wound, which is curved towards the fissure. The flap is left loose, and attached only by mucous membrane. On the other or smaller side of the lip,

where we generally find the tissues thin, especially as we approach the nostril, the treatment is quite different. I transfix the lip at d, close to the nostril, and carrying the knife along parallel to the margin, as far as f, I detach a moderately broad flap, which I leave adherent above to the ala nasi, and below to the free margin of the lip well beyond or external to the rounded angle at the fissure.

This flap, which (unlike the one at the opposite side) comprises all the tissues of the lip, is now divided into two at its centre (c e). I thus get two loose flaps, a superior (c d) attached to the ala nasi, and an inferior (ef) hanging on to the free margin of the lip. The loose end of the upper flap is turned up so that its raw surface faces the wound in the opposite side of the fissure, and the loose end of the lower flap is similarly turned down. The point c is brought up to a and fastened there. The point e is brought down to b and fastened there. I have thus got on the small side of the lip a wound as extensive as that on the larger side. The upper flap completes the outline of the nostril. The lower one supplements the outline of the free margin of the lip. I thus get a lip nearly double in depth what I could possibly have got by the ordinary incisions (Fig. 2). I shall revert to the treatment of double hare-lip further on.

Fig. 2.

g..d hf

5. I use, as a rule, sutures of horse-hair, as being less cutting than wire and less irritating than silk or thread. Pins, except every fine insect pins, I have discarded. Even these I use but rarely. A well-tied suture holds the parts together with sufficient firmness. It can be removed at any time, whereas the pin must remain until it becomes loosened in its bed by suppuration; hence the mark of a suture is trifling compared with that left by a needle or pin. The spot which requires a pin most frequently is the ala of the nostril. It tends to revert to its old position with more force than the lip, and it often needs the stronger pull of a pin.

I generally insert the upper suture first, then the one close to the line of junction of the red and white, then the two intervening sutures, in the order that seems most suitable in each case. Sometimes I have inserted a suture on the inner or mucous surface of the lip. Sometimes this is not necessary. Generally I put a fine suture just along the free margin to keep the lower flap in its new bed until it contracts adhesions there.

The sutures are removed, one after another, those near the margin first, the upper two last. As to time of removal much will depend on the age of the child, and on the firmness of its flesh. Thus in a strong child a suture may be left three or four days, while in one more delicate it may have to be removed in forty-eight hours. Sutures should never be left long enough to

ulcerate.

6. By this treatment of the sutures, plasters and dressings are dispensed with until some days have elapsed. They are applied only when the sutures are removed, and with a view to prevent the lip from thinning. I generally find that all the wound heals by first intention, and the presence of plasters rather interferes with this process, at least so long as the sutures are left. When plasters are used they have to be removed when we wish to inspect the lip, and their removal disturbs the delicate process of union. By leav

ing the wound uncovered we can watch the progress of the cure, and it is easy to apply a strap at any moment if it be really needed. The use of Hainsby's truss will, in most cases, make it quite unnecessary to use plasters of any kind. Collodion is sometimes useful, but it should be made very thick. The ether in thin collodion acts injuriously on the healing process.

As to the age for operating, I have done so successfully in a child under three weeks, and I have seen others of twice as many months on whom I refused to operate. The question is entirely one of the strength of the child, and the firmness of its flesh.

With regard to complicated double hare-lip, the first point to be attended to is, in like manner, the strength of the child, which, as a rule, is far below par. When, by careful feeding, this has been brought up to a proper state, the protruding intermaxillary bone has first to be replaced. It should never under under any circumstances be removed. This is, in fact, so well established an axiom of surgery, that it need not be insisted on. It is not always easy to bring it into its proper site. There are three methods to choose from; one is to separate it completely from all bony attachments, and to leave it for a time pendulous, adherent only to the central portion of the lip. This is the best way when practicable. The second is to take a Vshaped piece out of the vomer. The third is a new method which I have tried, and which has the advantage of helping materially to lessen the gap in the palate. It consists in cutting off an oblique portion of the vomer along with the intermaxillary bone. Whichever method is adopted, the bone is best left undisturbed for a few days after this stage of the operation. Nothing is more fatal to success in these cases than the effort to do too much at a time. A few drops of ether will sufficiently anesthetize the child to prevent its being frightened by repeated operations; success of the highest kind can only be obtained by doing the operation bit by bit. It is easy no doubt to conclude all at one sitting-but not to conclude all well. I therefore advise that,

as a rule, the bone when detached in any of the above methods, should be left undisturbed for a few days before any attempt is made to push it back or retain it in its new position. Yet if it goes back easily, the remainder of the operation may be done at one sitting.

I treat the middle bit of skin as in simple hare-lip, paring its margin in a curved manner, and leaving the parings attached by the mucous membrane; the outer portions are treated exactly as in single hare-lip, and the sutures are practically the same. In double bare-lip they are best inserted, and tied from below upwards. The amount of the central portion which can be made to contribute to the lip, is never very great, and the strain on the upper portion of lip is often very considerable. In these cases the use of Mr. Hainsby's truss is of the greatest service.

It is surprising how beautifully the flaps, made after my method, fall into and fill up the places intended for them; how naturally the form of the nostrils is restored, and the curves of the lip. The faithful woodcuts of Mr. Oldham show the perfection of outline, and the great increase in depth of the lip as contrasted with the results of the old operation.

In conclusion, I recommend this improvement in plastic surgery to the kind consideration of my professional brethren. I am satisfied that when tried it will be found a real advance in operative surgery, and one that all will confess was much needed in this department.-Dublin Quarterly Journal, May, 1868, p. 292.

63.-ON HARE-LIP.

By HAYNES WALTON, Esq., Surgeon to St. Mary's Hospital.

[The cases referred to in the following paper were all of the single complicated variety, in which were involved the lip, and the upper jaw on one side.] The first question to be discussed is the period at which an operation should be undertaken for the closure of the lip. My own experience tells me that it should be done as soon as possible after birth—that is, within the month—in

all cases which, like those under consideration, the bone is divided as well as the lip. Except the lip be closed the child cannot nurse, and even fails to take sufficient food in any other way because it cannot swallow quickly all that is put into the mouth; and emaciation ensues, and renders it less fitted for the operation, and is often the cause of death. Many surgeons are deterred from operating so early from the fear of fatal convulsions; but it is my belief that the liability to such has been greatly over-rated-that their appearance is due to loss of blood, and not to the mere irritation of the operation, and that more lives will be saved by operating a week or two after birth than by doing so some weeks or months later, when the child has all the marked symptoms of starvation, and is therefore unfitted to lose a drop of blood. I have myself operated many times before the child was a month old, and in every instance with perfect success. It has been erroneously supposed that in very young children the flesh is so soft that the pins or sutures readily cut through it. I say, therefore, as soon as the unfortunate child is born, have it fed most carefully and sufficiently long each time, till enough, or nearly enough, milk is consumed, and operate early, and before emaciation sets in. When the lip is united it can suck, or be fed. In those cases in which the lip only is cleft, the operation may be delayed without disadvantage, because the taking of food is not interfered with. In the miserable child lately before us, about two months old, there was so much emaciation that I kept it in the hospital for a fortnight, and had it fed by a clever nurse, and so improved its condition a little. It seemed scarcely safe to operate on such an ill-nourished subject.

Whether it be better for the health of the child or not to give chloroform is not easy to decide. Sometimes I give it, and sometimes I operate without it; but of this I am certain, that at this early age the surgeon derives no benefit from its administration. The patient is too feeble to offer any resistance.

The lip is the portion of the deformity first to be operated on, and there are three steps or stages to be accomplished. Failure in any of them will be fatal to success. The first to be done is the paring of the edges, whereby it,is prepared for adhesion. This procedure is very often improperly executed. The child should be secured for the operation, and the operator should stand in a convenient position. These can be accomplished only by the operator sitting, and holding the head of the infant between his knees, while the rest of the body is supported by an assistant. I operate, as you observed, with a very narrow scalpel. I transfix above, and cut downwards in a curved direction, because when the two curved surfaces are brought together, the free edge of the lip is thrown sufficiently down. When the incisions are made straight in a A-shape, the edge of the lip is not natural, but there is a retiring angle, that which generally constitutes so much after-deformity.

The manner of dealing with the hemorrhage is simple. If the coronary arteries be compressed with the fingers, on one cheek by the operator and on the other by the assistant, no blood will be lost, if the operation be quickly done, that can hurt the child. The operation can be proceeded with while such pressure is being made. As soon as the lip is put together, the arteries cease to bleed. Every part of the edge of the fissure must be removed, together with some of the red portion, no matter how extensive may be the incision necessary to accomplish this. Few young surgeons have courage enough to take away a sufficiency. Attention should next be directed to the alveolar process. If there be the slightest projection, the prominence should be brought to the level of the rest, by snipping through the arch, at the spot between the lateral incisor tooth and the canine, with the forceps, and pushing it back. On no account should any part be cut away. The teeth are to be preserved, and the mouth made more perfect by following my plan. In my last case I was able to fill up the gap in the bone, as you saw. The loosening of the lip-that is, the raising of it from the surrounding parts -should now follow, and I do not know how I can impress on you the importance of doing it to the required extent, except by asking you to remember how extensive was my dissection, and telling you that without it there will be frequent failure of union. It must be so separated all round, even in the

direction of the nose, that it will hang loosely, and admit of being transposed so completely that there shall not be the slightest tension when the parts are brought together. You will not forget that the child's nose was fairly separated from the maxillary bones.

The last proceeding is the adjusting of the wound. This little practical fact which I giveyou will save you much trouble, and benefit your patient. Commence the adaptation from the lowest part. Begin by making the edges below correspond, and all the rest will easily fall into a proper place, no matter what the dissimilarity in the length of the two flaps. You saw how

carefully I did this with a soft iron pin. To complete the operation on the outside of the lip, I used two other pins, in all three of them. In securing the pins with the ligatures, I tie each separately, and it does not matter whether this is done with a single round tie, or by twisting the thread in the figure of 8. I generally end the whole by an internal suture near the edge of the lip, to ensure the healing of the mucous membrane. The best result will be got if you follow my steps, even better than the plans of Malgaigne and Langenbeck. The sutures are generally removed too early. Take out one pin at the end of four days, then another each day, and then the stitch. A truss for pushing the cheeks forward is useful in most cases. The parts are kept quiet, and any strain on them is prevented.-Lancet, Nov. 21, 1868, p. 662.

ALIMENTARY CANAL.

64. THE CURE OF CLEFT PALATE.

By THOMAS SMITH, Esq., Assistant Surgeon St. Bartholomew's Hospital, and Surgeon to the Children's Hospital.

[Hitherto the operation of staphyloraphy has never been successfully performed except at or after fifteen or sixteen years of age, because the consent and help of the patient himself is necessary. The plan of systematically dividing those muscles that tend to draw asunder the margins of the cleft, as suggested by Sir William Fergusson has nearly brought the operation to perfection, still the inability to cure the defect at an early age has never yet been got over.]

The advantages of being able to cure cleft palate in childhood will at once be conceded by those who are familiar with the deformity, and the inconveniences it entails. The imperfections of deglutition, taste and smell, and the unnatural thirst, will probably be remedied at whatever period of life the cure of the deformity be effected. But it often happens that the union of the palate by operation is accomplished too late to do more than slightly improve the defective articulation, though it may cure the nasal resonance of the voice.

A resolute and intelligent adult patient, after a successful operation, may acquire by his own efforts, or with the aid of an instructor, the power of distinct and normal articulation. But in some the difficulty of unlearning an almost life-long habit is well nigh insuperable.

It is probable that were the deformity of cleft palate cured in childhood, before or whilst the power of speech is being acquired, there would be but little difficulty in teaching a child to articulate distinctly.

It is at least certain that the earlier the cure was effected, the less difficulty would the patient have in learning to speak plainly.

The plan which I venture to introduce depends largely for its success on the employment of an instrument whereby the jaws are opened and fixed, the orifice of the mouth is dilated, and the tongue is held down; and this without in any way incommoding the operator, or encroaching on the small space at his command.

By the use of this instrument the patient is rendered perfectly helpless; the palate and fauces are brought plainly into view, and much more room is obtained for the manipulation of instruments that can be gained by the most