intention taking place throughout the entire cleft; in two of them union was obtained everywhere except the uvula and the extreme anterior portion. In four of them, the cleft was throughout the hard and soft palate, the others were partial, all involving the entire portion of the soft palate. The youngest child operated upon was two years old and the oldest sixteen. Authorities vary greatly regarding the best age at which to operate. On general principles, it may be said, that the earlier the operation can be performed the more successful will it be, particularly in its effect upon the speech function, but we must be governed wholly by the condition of the patient. We must remember that some children at a year old are stronger and more vital than others at four or five years of age.

It is never safe to promise perfect articulation even if the result of the operation is perfect from a mechanical standpoint, because imperfect innervation or loss of co-ordination is always possible. Defects in articulation identical with those produced by cleft palate are not uncommon in children, where the nose, naso-pharynx and larynx present no visible abnormalities. Patients who have already begun to converse and who have formed their habits of speech must, after the operation, receive prolonged training in pronunciation in order to obtain satisfactory results.

Careful preparation for the operation is important, and so the patient should be under immediate observation for some days previously. Catarrhal difficulties of the nose and nasopharynx should be corrected and hypertrophies of the faucial and naso-pharyngeal tonsils should be removed long enough previous to the proposed work on the palate, to insure a healthy condition of the tissues. For two days previous to the operation the nose, mouth, and teeth should receive special care. The nose should be irrigated with a warm Dobell's solution, two or three times daily, and the mouth and the teeth thoroughly cleansed after each feeding with alphozone or a boracic acid solution.

The operation is performed as follows: Place the patient in the so-called Rose position, anæsthetize with chlorform and oxygen or ether and oxygen, forcing the vapor through a catheter which is inserted in one of the nasal passages, until it is well down against the posterior pharyngeal wall; hold the mouth open with the mouth-gag and pull the tongue forward by inserting heavy silk through the end. Now inject into the tissues of the palate along the edges of the cleft and laterally on each side near the alveolar process, a 1-1000 solution of one of the alkaloids of suprarenal extract. One or two drachms may be safely used. This, if well injected, will control the hemorrhage, sometimes entirely, and always to a considerable extent. The first part of the operation is almost identical

with the flap operation usually employed, that is, the edges of the cleft are freshened, lateral incisions are made close to the alveolar process on each side, this incision being about onequarter inch anterior to the cleft and extending backward well to the beginning of the anterior faucial pillar. The length of the incision must, of course, depend upon the length and width of the cleft. The flaps are now elevated, including the periosteum, and particular attention should be given to the separation of the mucous membrane on the superior or nasal side of the hard palate. This separation can be accomplished by elevating the flap with forceps and cutting away the posterior reflected mucous membrane by an incision at right angles with the lateral wound. At this point the soft palate should come together easily without much tension. The putting in of the sutures is next accomplished by means of a hook needle with the eye in the end, and braided silk has proved the best material in the hands of the writer. Up to this stage there has been no marked variation from the ordinary flap operation, except in the use of the Adrenalin injection, which originated with the writer so far as he can learn. The remainder, however, differs from the ordinary, as will be seen.

Before the inserted sutures have been tied, have prepared a piece of stout tape, three-quarters of an inch wide, and six inches long, and covered with a piece of tissue rubber tubing. This can be readily accomplished by passing the tape through the tubing and smoothing it out nicely. Pass one end of the rubber-covered tape through the muco-periosteal incision, carrying it along behind the cleft and out through the incision on the opposite side. Now tie the sutures and then bring the ends of the rubber-covered tape together sufficiently to relieve all tension from the sutures and hold together by snapping on two of the small metal clips designed for uniting superficial skin wounds. After this has been accomplished it will be found that all tension has been relieved except about and just above the uvula. If the finger is passed over the hamular process, it will be found that the tension is produced by the tensor palati muscles on each side. To relieve this, an incision is made through the mucous membrane and with the handle of a knife the muscles are partially separated and thoroughly stretched. It will then be found that the tension of all the soft palate is relieved. After treatment is simple. The patient is given only sterile food and sterile water, great care being given to the sterilization of spoons and dishes. On the seventh or eighth day the tape can be removed and on the fourteenth the silk sutures. This operation is not entirely original with the author. The idea was taken from a paper written by Dr. Chas. H. Peck of New York, entitled "The Operative Treatment of

Cleft Palate," the writer simply making a few modifications in his method.

It would seem that the wide separation of the flaps from the bone would result in failure of nutrition and cause sloughing, but such is not the case. There is ample blood supply from the anterior and posterior attachments and no anxiety need be felt on this score. Three months after the operation there is hardly a scar left over the site of the lateral incisions, so kindly do the parts heal.

Failure will, of course, occur in poorly nourished children, or in those suffering from hereditary or acquired syphilis. Infection may cause sloughing, as might be the case in any surgical operation, but the claim is made, that in this operation more than in any other with which the writer is familiar, the principles are correct and that little is left to chance. Instruments necessary are a long, slender knife, long curved scissors, two or three periosteal elevators of different curves and sizes, a long hook needle with eye near the point, a right and left curved needle with eye near the point and an attached slim handle, a blunt hook, a number of pairs of artery forceps and a pair of long mouse-toothed forceps, and a box of metal clips with forceps for snapping them on. For sutures, fine and coarse braided silk. The tape has been before described.

(DISCUSSION OF DR. RICE'S PAPER.)

Dr. A. H. Powers: This paper is certainly very interesting, and more so because there is, as Dr. Rice has said, so little that is satisfactory in the way of literature in regard to this operation. These operations, of course, are not so very numerous in the total, and yet the amount of discomfort and embarrassment to the patient is very considerable, and the immense amount of ingenuity that has been set to work to overcome this defect is certainly a credit to the medical profession.

We find all sorts of ideas, some claiming that operation is never adequate, that something in the line of an artificial plate serves much better. Then there are all sorts of ideas in regard to the time when the operation should take place. I am glad Dr. Rice has presented some unique features in regard to the matter. The first is that in regard to the use of some of the suprarenal extracts, lessening the hemorrhage which in some cases has resulted fatally to patients from the irritation of the larynx and trachea and possibly by the setting up of a pneumonia. The use of this solution is undoubtedly a step in the right direction.

Then the other point is that of the use of the tape, which was brought out, I think, in a paper three or four years ago, but I do not imagine was very largely adopted. Here the use of the

rubber outside the tape is certainly a very considerable improvement, as plain tape would be likely to catch any septic material, if such should reach it, while the rubber would allow it to pass more readily. There is, of course, constantly in the atmosphere a certain amount of septic material likely to pass in and out, and although Dr. Rice has guarded against sepsis in the best possible manner, yet I question if a mouth would ever be absolutely sterile. I think culture of some sort would undoubtedly be found, even in well sterilized mouths.

The relief of any tension is undoubtedly a special advantage of this operation.

A query comes to my mind since hearing the article, as to whether a plain strip of rubber might not serve quite as well as the tape inside with the rubber outside.

Another query, as to the possibility of the use of chromicized cat-gut. The advantage, it seems to me, would be that cat-gut does not have a capillary action, while the braided silk always does. Those are the only two modifications that come to my mind, and those are simply from a theoretical standpoint. From my experience on other mucous membranes I have found that a thoroughly chromicized cat-gut serves better than any other suture material I have ever used. It seems to me that cat-gut could be chromicized so that it would last sufficiently long.

My own belief is that this operation should be attempted as early as the child's strength will allow it. My observation would seem to be that they speak much better. Anywhere

from two to four or five years gives better results in the final outcome of the case.

A still further point in regard to this operation which commends itself is the fact that there is so little dressing and foreign material left within the roof of the mouth. We all of us, I think, have seen operations where a considerable amount of suture material was left in the mouth, which is very irritating to a young child.

A CASE OF ADENOCARCINOMA

AT THE FUNDUS

UTERI WITH PERTINENT REMARKS.*

BY H. A. WHITMARSH, A. M., M. D., PROVIDENCE, R. I.

Mrs. S., aged seventy-six, had passed comfortably and naturally the menopause at fifty. With no discharge for more than twenty years she again noted a slight flow of bright red blood. This on one or two occasions amounted to a drachm or two, but rarely exceeded a slight show, and would be altogether absent for weeks at a time. No other symptom referable to the pelvis, Read before the Massachusetts Surgical and Gynecological Society, June 13,

1906.

such as pain, leucorrhoea or pruritus could be elicited. General health, too, was excellent.

This irregularly recurrent flow continued a year and a half, when, at the suggestion of her physician, she visited me last November. Examination revealed a tumor on the right side entirely within the pelvis, not of the uterus but separable from it, elongated, irregular and elastic. This I deemed an ovarian or tubo-ovarian cyst, and seemingly a more important factor than the uterus itself for the following reasons:

First, the latter organ though enlarged was no more so than readily accounted for by one or two subserous fibroid nodules felt in its wall.

Second, a most innocent-looking polyp was seen at the external os, a more direct cause for the flow and another cause for relaxed uterus.

Third, small tumors of the adnexa are often a cause of enlarged uterus and also of uterine hemorrhage. Indeed, curetting is sometimes unsuccessful not because unskillfully or hurriedly performed, but because the endometrium will after a few months develop new vegetations, more readily, I think, in a uterus relaxed and congested by neighboring small growths.

The case then is thus briefly before us. What shall we advise? First is operation necessary? Second, is operation feasible? And surgical science has to do quite as much with question one as with question two. We shine, perhaps, more brillantly in successful operating, but are worthy of greater praise when our knowledge is sometimes even more severely tested in deciding that not to operate is better.

Fifteen years ago few surgeons would have ventured to advise conservatism in a cyst of this size. But small cysts in the pelvis may remain small, and if they produce no symptoms may be left undisturbed for an indefinite time. I believe this to be true not only of parovarian and broad ligament cysts, but also occasionally of those strictly ovarian. But for this patient there are two important questions. First, is the uterine condition as simple as it seems to be? For uterine flow occurring long after the menopause suggests malignancy. Second, is the cystic tumor growing? An affirmative to either of these questions would decide for early operation. Her physician is confident that there has been no material change in the pelvic organs since his first examination a year or more ago. Again the patient is imbued with the thought that she is too old for successful operation, and also has gained the impression that the condition itself is one not amenable to surgical interference. Hence though inclining to immediate exploration by curette to settle the question of cancer higher up in the uterus (the cervix certainly was not cancerous), and telling the patient that I regarded this the safer course, I yet suggested