HARELIP kLateral upper labial cleft, labium leporinum, Pathological Anatomy.—The fissures may be large or small, uni lateral or bilateral, but confined to the lip (Figs. 10a and lob, Plate 1); or they may involve the corresponding deeper soft parts, like the upper maxillary process (gnathosehisis) or the palate (palatoschisis) (Figs. lla and 11b, Plate 1). From a slight retraction of the lip to the high degrees of fissure described there may be a number of intermediate stages. Those of the higher degrees extend into the nasal cavity, the alm nasi losing their normal curve and stretching flat over the fissure to the extreme border of the cleft (see Fig. 12a, Plate 1).
The red color of the lips continues practically uninterrupted, but is drawn up into the fissure (Fig. 11a, Plate 1). A complete labial cleft unites with the nasal mucosa (Fig. 12a, Plate 1), and frequently there are membranous bridges and apparent scar traces as signs of incomplete transition which, according to Trendelenburg, should be regarded as late unions or raphx and not as cicatricial formations.
Bilateral harelips may also occur as simple fissures; more frequently, however, they are deeper clefts (bee de lievre complex) (Figs. 12a and 12b, Plate I).
According to Kolliker the cleft extends between the intermaxillary bone and the upper maxillary process, or according to Albrecht between the internal and external intermaxillary bones, passing through the dental process of the upper maxillary bone and the roof of the buccal cavity in greater or smaller width.
This complication of harelip with palatal cleft, which is known as "wolf's throat," is the highest degree of deformity and nearly always associated with considerable disfigurement of the entire facial skull (Fig. 12).
The deformity most difficult to remove in after-operations is the oblique displacement of the int-ermaxillary bone in unilateral harelip (Fig. I la, Plate 1) and its protrusion in bilateral harelip (Fig. 12a, Plate I). It would seem as if nothing but the closure of the lips could guarantee the normal direction of growth of the intermaxillary bone. An exces
sive growth towards the open gap nearly always occurs when they do not close. When old operated cases were re-examined, it was found that pronounced oblique displacement had been equalized by the pressure of the lip by operation (Fig. 12b, Plate 1).
The behavior and direction of the teeth are of interest. Frequently they stand at right angle to the fissure and sometimes they are directed outward, a fact which should be considered in the operation (removal of oblique teeth before operation).
As regards the teeth, the fissure runs between the canine tooth and the second incisor (Kffiliker) or between the first and second incisors (Albrecht). Owing to the frequent dental anomalies (3 incisors) it is often difficult to account for the history of development of the fissure.
The prognosis of the untreated harelip varies according to the degree of the cleft, but even the lightest degrees imply such a consider able disfigurement of the face that parents ever so averse to operations can hardly bring themselves to let the child grow up with this stigma upon him. In complete complicated fissures nutrition is impeded: besides, owing to the absence of the nasal filter these children arc exposed to respiratory disorders and infection of the respiratory tract.
From times of antiquity it has always been the desire of both parents and physicians to correct thus deformity as early as possible, and for this reason surgeons practised it in pre-antiseptic times. In spite of improved technic and after-treatment the operation still involves many dangers, Ivhich consist principally of hemorrhage, of traumatic infection, and not least of the gravity of the operation itself. In my experience, which comprises 132 cases, the operation is well borne by children, and the mortality is exceedingly small and a direct danger to life can be completely avoided by selection of the proper cases and the suitable time for operation.