portions on either side should be well freed from the bone so that the two portions fall together quite readily, but it is not advisable to cut into the septum to do this.

Tension sutures of silkworm are used. The first suture is placed just inside the nostril, being passed in through the mucous membrane and brought out beneath the skin or the outer portion of the lip just inside the ala of the nose. It is then put in again just beneath the skin. and passed out through the mucous membrane on the central portion of the lip close to the septum. When this suture is tied the flattened nostril is rounded up into shape. Two silkworm sutures are used to approximate the lip and these are tied on the inside of the lip. As they do not pass through the skin there is no scarring from the tension sutures. Horsehair

sutures are used to approximate the skin. After the upper two-thirds of the lip is approximated the surplus of the pared edge is trimmed off and the lip closed with horsehair. In order to avoid an unsightly notch, it is necessary to leave a little excess of tissue at the lower part of the vermilion border so that the lip pouts a little. This is best accomplished by leaving the parings long until most of the lip is closed, when one is better able to judge how much should be excised. (Figs. 1, 2, 3, 3A, 4, 4A, 5, 5A, 5B, and 5C).

Technic of Cleft Palate Operation.

After the child is anesthetized the head is brought over the end of the table and allowed to rest in the lap of the operator, who sits on a stool at the end of the table. A Whitehead

mouth gag is used and with a tongue depressor the tongue is lifted giving a good exposure of the palate.

In closing a single cleft palate an incision is made on either side close to the alveolar process or teeth, and carried down to the bone. It is just long enough to admit a thin, blunt periosteal elevator. By keeping the incision close to the alveolar process or teeth the posterior palatine artery is avoided. Injury to this artery may interfere with the blood supply of the flap.

With a periosteal elevator the mucoperiosteum is elevated over the entire hard palate down to the cleft. With a scissors the soft palate is liberated from its attachment to the posterior margin of the hard palate, and the entire mucoperiosteum of the palate margin is freed as much as possible. The soft palate is attached to the hard palate margin by the palatine aponeurosis and there is no danger of cutting any important vessels at this point. The freeing of the posterior margin of the hard palate from the soft palate is very important either

in closing a cleft of the soft palate or in a complete cleft palate, since it is advisable to sever this aponeurosis in order to approximate the margins of the palate. The mesial margins of both sides of the palate are freshened by fixing the uvula with a stomach clicker and trimming the mucous membrane from the free margin with a scissors or knife. The procedure is begun posteriorly and extended forward.

Silk sutures are used, the first one, a mattress suture, being placed at the juncture of the hard and the soft palates. From this point the rest of the soft palate and uvula are closed by interrupted sutures along the oral and nasal mucous membrane. By leaving the ends of the sutures long and fixing them with forceps as they are put in, the uvula is brought up into the mouth and the insertion of the sutures is made easier.

The completion of the closure of the hard palate is accomplished by mattress sutures, usually two, and occasionally an interrupted suture. It is best not to use too many sutures in approximating the margins of the palate; if the

DISCUSSION.

DR. R. E. FARR, Minneapolis: Dr. New has given us as comprehensive a resumé of this subject as is possible considering the time consumed. He has called attention to many of the essential principles which must be adhered to in order to obtain results which are at all satisfactory.

I do not believe there is as large a percentage of failures in any other field of surgical endeavor as there is in the treatment of these cases. In my experience it is the rarest thing to see a satisfactory result. The closure of the lip is a simple plastic operation. Secondary operations upon the palate present such a diversified array of conditions that it is difficult to lay down rules to fit them all, but in general they should be treated on the principles laid down by Dr. New.

I shall limit my discussion to the child born with a complete cleft between the alveolar processes. With regard to the method of handling these cases I

late as Dr. New states, between the ages of twelve and eighteen months, preferably just before the child begins to talk.

SOME POPULAR FALLACIES REGARDING PEDIATRICS.

WALTER REEVE RAMSEY, M. D., Assoc. Prof. of Pediatrics, University of Minnesota.

To say that the child is the most important element in the future of the state is axiomatic. There never was a time when this fact was so apparent as now, and yet there is no department in the whole field of medicine which is so

type, you remember, the nose remains in the center line and the premaxilla protrudes. I agree with Dr. New that the removal of the premaxilla is nothing less than a calamity. I also agree that it should not be forced backward between the alveolar processes with the inevitably resulting fish mouth. I do believe, however, that it is desirable in these cases to establish a bony union between the premaxilla and the two alevolar processes after the latter have been approximated to a proper degree. A nearly normal bony roof may thus be formed. The simple closure of the lip-while it does narrow the arch somewhat -never gives a bony union between the parts, and leaves a much more difficult operation when the palate is closed. An examination of the bipartite cases will show that the midline of the face divides the ala of the nose at about the mid-point, whereas it should divide the nose in the center. In every case of this type that I have examined, where the lip was closed in infancy, the nose shows this deformity to some degree. The alveolar arch does not unite in front and I believe does not develop as well when there is no bony union between the alveolar processes. On the other hand, early reposition of these processes with the establishment of bony union between them allows one immediately to close the hard palate, brings the nose at once to the mid-line of the face, makes the lip operation more simple and easy, and, what is most important in view of the failures that occur, overcomes the almost unsurmountable obstacles to later closure of the palate. In cases that are handled this way there is always more soft tisue than is necessary and lateral incisions need never be made.

The plan I advocate, therefore, is as follows: The immediate reposition of the displaced parts, which may be bent with the thumbs during the first few days or weeks of the child's life; closure of the lip from six to ten weeks later, and a closure of the pa

as that of pediatrics.

Up to a few years ago there was little exact knowledge concerning the fundamental principles underlying the field of pediatrics, but today the care and feeding of infants and children rests upon as solid a scientific foundation as does general surgery.

There is perhaps no department of medicine where tradition still plays so prominent a part as in the care of children. The fatalistic and to a great extent false doctrine of "the survival of the fittest" has been slow to be discarded and rational science applied in its place. It is an every-day occurrence to hear statements made by prominent physicians relative to pediatric subjects, which in the field of surgery would be comparable to a return to the carbolic spray of Lister.

The common error in believing that new-born infants must be bathed as soon after birth as possible is responsible for many deaths. This is especially so in those who have been subjected to a long labor, to considerable exposure in the process of artificial respiration or for some other reason. Young infants lose body heat rapidly when exposed to cold, resulting in subnormal temperature, a marked lowering of vitality and frequently in pneumonia. Such new-born infants should be rubbed with warm oil, wrapped in warm blankets and allowed to remain from twelve to twenty-four hours in a uniform temperature of from 75° to 80° F.

without bathing. The diffuse intense redness of the skin so frequently seen after the second or third day usually results from too much friction in the effort to remove the vernix caseosa, and the use of improperly neutralized soap.

Another popular fallacy is that the mouth of the infant beginning with birth should be daily swabbed, the common technique of the nurse being to stretch a piece of gauze over the index finger and with more or less force wipe the inside of the mouth as thoroughly as possible. This is perhaps the most common cause of stomatitis. The gauze removes portions of the delicate epithelium and wherever removed a white patch of exudate results. The mouths of infants do not need swabbing, unless they are already diseased, until the teeth come through, after which the teeth should be brushed daily.

The practice of putting the baby to the breast every two or three hours during the first days is also erroneous and responsible for many failures in nursing. The colostrum is laxative in character and usually, although not always, scant in quantity. In cases which are fed frequently during the first days a diarrhoea with. curdy green stools often results. A dyspepsia which occurs at the onset, often results in a marked intolerance to food which is difficult to overcome and frequently leads to weaning.

The common practice of ordering a dose of castor oil for the baby on the third day cannot be too strongly condemned. Its effects are more or less irritating, it sweeps the intestinal canal clean so that no natural movement can logically be expected for several days, since the secretion of milk has hardly been established at that time. Owing to a lack of knowledge on the part of all concerned the first dose of oil usually leads to a second and third to be followed by enemas and suppositories when the bowels fail to move on the succeeding days. Finally serious intestinal irritation is set up with green, frequent, curdy stools. After a short time the milk is adjudged "bad" by the physician and the baby is weaned. Injections, including enemas and suppositories should almost never be given young infants. Breast-fed babies may go several days without a movement without any disadvantage and if allowed to do so will rarely suffer from constipation. The stools in breast-fed infants are rarely even

semiformed so that a sufficient effort will be made to produce an evacuation when enough fecal matter has accumulated in the rectum to produce sufficient stimulus.

The prevalent idea among physicians that many mothers cannot nurse their babies is false. At least 90 per cent of mothers can nurse their babies in whole or in part for the whole or a part of the first year. Because a mother has insufficient milk is no reason for weaning the baby. It should be given all she has and the remainder of the meal made up with properly modified cow's milk. The failures in nursing are nine times out of ten due to falty technique and a lack of observance of the simplest and most fundamental rules.

There is, practically speaking, no such thing as bad breast milk. A baby which is having frequent green curdy stools on breast milk has simply been having "too much of a good thing."

An analysis of a portion of the milk, or even the whole content of one breast gives usually fallacious information. The fat content of different portions of the milk from a breast differs widely. It differs widely at different nursings and on different days depending on the food of the mother, whether she is tired or rested, as well as upon her mental condition. Such examinations frequently result in the milk being adjudged "too rich" or "too poor" and the baby weaned.

Infants who are gaining properly in weight are always getting enough food and frequently too much. Many cease gaining until the amount of food has been properly reduced.

Before weaning a baby remember that the death rate in artificially fed infants is from seven to ten times greater than in breast-fed babies and that by proper technique babies may be kept on the breast at least partially in almost all cases. Open tuberculosis of the mother is one of the few things which will excuse her from nursing her baby.

Regarding the artificial feeding of children, which too often becomes necessary, many erroneous ideas are prevalent. That cow's milk or any other food, patent or otherwise, can be juggled in its percentages to even approximate