broad and flattened, the ala being
bound down to the alveolar margin of the maxilla by fibrous tissue.
The margins of the cleft in the lip are also attached to the alveolus
by firm reflections of the mucous membrane. The orbicularis oris and
other muscles of expression about the mouth being defective, the
deformity is exaggerated when the child cries or laughs. In simple
hare-lip the child may have difficulty in sucking, but this can
usually be overcome by some mechanical contrivance to occlude the
cleft.

When the _hare-lip is double and combined with cleft palate_, the
child is unable to suck, and food introduced into the mouth tends to
regurgitate through the nose. The nutrition can only be maintained by
having recourse to spoon-feeding, and in feeding the child it is
necessary to throw the head well back and to introduce the food
directly into the back of the pharynx. Many of these infants are of
such low vitality, however, that in spite of the most careful feeding
they emaciate and die.

In those who survive, the voice has a peculiar nasal twang, as in
phonation the air is expelled through the nose instead of through the
mouth, and the articulation, especially of certain consonants, is very
indistinct. Taste and smell are deficient. The constant exposure of
the nasal and pharyngeal mucous membrane renders it liable to
catarrhal inflammation and granular pharyngitis.

_Treatment._--The only means of correcting these deformities is by
operation, and, speaking generally, it may be said that the earlier
the operation is performed the better, provided the general condition
of the child is equal to the strain. In simple hare-lip the best time
is between the sixth and the twelfth weeks. When cleft palate coexists
with hare-lip, the lip should be operated on first, as the closure of
the lip often exerts a beneficial influence on the cleft in the
palate, causing it to become narrower.

Considerable difference of opinion exists as to when the cleft in the
palate should be dealt with. Some surgeons, notably Arbuthnot Lane,
recommend that it should be done in early infancy, as soon as the
viability of the child is assured. We agree with R. W. Murray, James
Berry, and others in preferring to wait until the child is between two
and a half and three years old. It should not be delayed longer,
because, even if the cleft in the palate is repaired, the nasal
character of the voice persists, as the patient cannot overcome the