648 on either side of the fibrous attachment of the soft palate to the bone, and dividing freely. This proceeding allows the parts to fall, and in most cases to come together with very little interval, and is a most essential feature of the operation. The pared edges of the soft palate can then be brought in contact by means of horsehair stitches passed on rectangular needles, and the silver wire, which is passed by means of Smith's needle through the anterior portions of the cleft, can be

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... ed as far as is thought prudent, and can be further tightened up before the operation is concluded. The former methods of avoiding tension by dividing the muscles, the palato-glossus, palato-pharyngeus, and levator palati, are now simplified by using a free incision, which runs from near the alveolar margin in front, parallel to the edges of the flap, backwards to the middle of the soft palate. These being made on either side, allow the approximation of the raw edges when the wire stitches are finally twisted up. Notwithstanding that the bleeding is often free, it generally stops with a little firm pressure with a sponge ; and although it has happened that the haemorrhage has been so serious as to necessitate plugging of the posterior palatine artery in its canal, which is not difficult to find, I have fortunately never met with such an accident. The after-treatment calls for the greatest patience and tact on the part of the nurse. The child must be prevented from crying as far as possible, and nothing but fluid food should be given for the first ten days, after which fish and chicken may be allowed, but must be finely divided and passed through a fine sieve. Unless there is reason for doing so, I never permit the mouth to be opened for inspection until the end of a week after operation, and the patient must not be permitted to talk for a still longer period. The stitches need not be touched until union is firm, and may be left for several weeks if the superfluous wire has been cut short to prevent it catching the food or irritating the tongue. If draughts are avoided the patient may be dressed, and allowed to move about in the course of a week, or even less. The results obtained will naturally interest you, and from the books of this hospital and of the Hospital for Sick Children, and from my private note-books, 1 find that I have performed the operation on sixty different individuals, some of whose cases required a second, a third, or even a fourth additional sitting m order to effect complete closure. Two of these were adults, in both of whom the greater part of the fissure was united. One was a widow of twenty-seven, the other a young man of nineteen, the cleft being congenital in both cases. The remaining fifty-eight were children of different ages, the time for operation depending upon the considerations just mentioned in most cases, or, as in some, upon the age at which they were first sent to see me. Of the total number one child died of diphtheria, contracted during an epidemic which occurred soon after the operation was performed; but, including this, only seven failed entirely at the first sitting, and of them two were treated successfully at a subsequent operation. Twenty-eight cases were 11 partially successful"; that is to say, more or less union was obtained at the first operation, and of these nine were subsequently completely closed. Probabiy the latter number would have been much increased both under the first and second headings but for the unfortunate propensity of the lower classes to neglect to bring patients to be seen again after an interval, since it is a gratifying and decided fact that second operations in these cases are attended by a very large proportion of satisfactory results. In the remaining twentythree cases complete union was obtained at the first operation. Thus out of fifty-eight cases there were thirty -four for whom the cleft was entirely closed, nineteen in which it was partially united, and only five failures, results which, considering the difficulties surrounding the operation and the delicate condition of most of such patients, are exceedingly satisfactory. Probably owing to better nutrition, cases in private practice are more often successful than in hospital. Where the cleft is very wide, or where failure has attended a first operation, Sir W. Fergusson, following Dieffenbach, advocated a method by which the horizontal portion of the bony palate was punctured by a chisel, and levered towards the corresponding part on the opposite side, to which it was secured by wire sutures. I have seen this plan adopted with euccess in a case which had failed after the ordinary operation, but have never had occasion to follow it, and I should prefer in such cases to carry out the ingenious suggestion which has been recently advocated and successfully carried I out by Mr. Davies-Colley, which consists of carrying a 6 across from one side of the hard palate to the other. If you are fortunate in obtaining complete closure of the cleft, there remains the trouble of getting rid of or modify. ing that peculiar intonation which is so great a drawback to, subjects of this deformity. A very great deal can often be done in this direction, either by those who make a special study of the correction of these defects of speech, or by patient tuition on the part of any persevering and intelligent person. But even if little can be done in this direction, you will find those patients who are old enough to remember the inconveniences connected with their former state, be. cause, as a young lady who had had her palate closed, and who brought her younger sister to me for the same operation, besides the improvement in the voice, there is such great relief from the inconvenience attendant upon swallow. ing and the lodgment of food in the cleft and in the nasal cavities. As has already been stated, the prospects of a radical cure in the true sense-i.e., leaving the patient entirely independent, under ordinary circumstances, of the use of trusses-are considerably less in these cases than m those previously discussed, the main obstacles to complete success being the large size of the ring, the rigidity of the structures, which render the approximation of the walls of the canal difficult and sometimes impossible, and the entire absence of any inclination to spontaneous contraction of the parts, excepting in hernia of very recent origin rarely seen in this class of case, which is almost always of long standing. It necessarily follows that the amount of' relief ultimately obtainable will often depend solely upon. the actual strength of the barrier across the internal ringy since the help afforded by the approximated walls of thecanal is in most cases not of much permanent value. The degree of the rigidity of the parts is determined to a great extent by the chronicity of the hernia; it also appears to be in direct proportion to the amount of omentum which the sac contains, whilst it is comparatively independent of the quantity of bowel. It has long been an, accepted principle in operations for the radical cure that all redundant or altered omentum should be liga, tured and removed, the stumps being returned into the abdomen and left to their own resources. Personally, I have for some time felt that by this wholesale remo-fa) valuable material is sacrificed, some of which should be utilised for strengthening the barrier across the internal ring-certainly in all inguinal cases of this kind, and in some umbilical hernise. Acting upon this view, I have been led to utilise the omentum in appropriate cases in the way described in the following operation, which is not intended to apply to instances in which merely a tag of recent omentum is found in the sac whilst operating upon younger subjects, in whom the ring is nearly always of moderate siz3, with supple margins. Details of the operation for the radical cure by the use of an omental pad in inguinal hernia.-The parts having I been exposed in the manner already described, the 800 I is opened and the bowel returned, any adhesions having I been dealt with in the ordinary way. The omentum is 1 now examined, and a flattened piece selected large enough to cover the internal ring and overlap its edges for some distance. Should there be no single piece of the ; desired size or shape, two smaller portions may be stitcheø together with carbolic catgut. In most cases, however, a suitable flap is obtainable by carefully disentangling the ! omental masses, especially when the structure has become large and nodular from spontaneous growth in the sac. In E an ordinary way it is preferable that the flap should I