MANAGEMENT
OF
THE
PATIENT
WITH
CLEFT
LIP
AND
CLEFT
PALATE
By Donald W. MacCollum, M.D,, and Sylvia Onesti Richardson, M.D. Surgical Service of the Children’s Hospital, Boston, and the Department of Surgery
of the Harvard Medical School
(Submitted March 22, accepted April 12, 1957,)
ADDRESS:(D.W.MacC.) 300 Longwood Ave., Boston 15, Massachusetts. 573
ARTICLES
D
URING the past decade an increasingamount of attention has been directed
toward developing better programs for the
care of children with cleft
lip
and cleft palate. Surgical technique and procedures have improved, new methods of cranio-facial measurements have been devised, and there has been a good deal of analytical “soul searching” by members of the medical anddental professions. It is now widely recog-nized that management of the patient with
cleft lip and cleft palate involves the
co-operative efforts of a multi-professional group, wherein the members may operate either as a team or as individual specialists. It is also generally accepted that the proper habilitation of these children depends on the continuity of total care in addition to the
actual surgical repair. There is some contro-versy, however, regarding the optimal age for operation and the type of surgical pro-cedure for reconstruction of both the lip and the palate. For the pediatrician, who is in-timately although indirectly involved, this has sometimes resulted in confusion, espe-cially with regard to his particular role in
the care of the child with cleft lip-cleft
palate deformity.
The elective age for repair of a cleft lip may vary from 48 hours to 8 weeks of age, but most surgeons prefer to carry out this procedure when the infant is
4
to 6 weeks of age. For many years the majority of sur-geons and speech therapists have consideredit preferable to repair a cleft palate during
the first 2 years of life, before the child has established a speech pattern. On the other hand, many orthodontists and
prosthodon-lists and some surgeons now prefer to delay
corrective surgery until the child is from 4 to 7 years of age. Cephalometric studies have been made which have been inter-preted to indicate that earlier surgery may retard or distort the bony growth of the maxillary complex.1 2 These two divergent concepts deserve further examination and study, but the need for delineation and
clarification of the practical details of
pa-tient care must not be forgotten.
Whether the child is treated by a “cleft-palate team” or
by
individual specialists,the pediatrician, by the very nature of his specialty, is responsible for the child’s total
care. He must act as an intermediate
be-tween the various specialists and the child’s
parents, and must be aware of the specific
problems involved in the management of
children with these anomalies, He should also be able to interpret the various pro-cedures to the parents and to evaluate the
individual child’s needs intelligently. Thus
he should be familiar with the details of the
“timetable of treatment” that has been scheduled for his patient. It behooves those
who are active in the care of cleft lip and
cleft palate not only to review their own
methods and results but to provide the re-ferring physician with the details and ra-tionale of their proposed plan of manage-ment.
With this purpose in mind we have
ex-amined our methods and have reviewed the clinical impression of the results ob-tained at Children’s Medical Center,
Bos-ton, in the 15-year period from 1942 to 1957.
574 PEDIATRICS OCTOBER 1957
performed for cleft lip or cleft palate or both in the Plastic Surgery Unit. Of this number, 2,123 patients had the repairs
carried out in the last 10 years. Mortality has been zero during the entire 15-year period and for some time prior to it. Most of the operations were performed by one surgeon, but some were done by a resident under his direct supervision. Surgical pro-cedures and the routines of pre- and post-operative care were well established before the period under consideration.
In addition to the clinical appraisal of
this 15-year period, a detailed evaluation of the long-range results of our cleft-palate program was undertaken in 1954-1955. Clinical experience in this clinic had not confirmed the bony distortions of the face that have been reported from other clinics and interpreted as being due to early
sur-gery on the palate. Also, we believed the
children whose palates were repaired before the establishment of a speech pattern had such good speech that we were warranted in continuation of our policy of early
sur-gery. The results of this study, which are
summarized herein, corroborate our clinical impression.
It is our opinion that many of the compli-cations which have been attributed to im-proper time of surgery on the palate more likely have been due to either ill-conceived, poorly executed surgery or to improper over-all care of the patient. Rehabilitation of the child whose initial treatment was in-adequate undoubtedly necessitates the sub-sequent attention of a team consisting of specialists from many different fields. How-ever, we have seen that satisfactory habili-tation can be achieved by proper surgical repair with meticulous attention to the de-tails of pre- and postoperative care, coupled
with diligent speech and dental programs and active co-operation of parents. We pre-sent a description of the surgical manage-ment and adjunctive care of children with cleft lip and cleft palate at this Center; included are the details of supportive care which we consider most important.
MANAGEMENT OF AN INFANT
WITH A CLEFT LIP
Time and Method of Repair
For over 20 years it has been customary at this Center to repair a cleft lip when the baby is 2.7 kg (6 Ib) in weight or over,
exhibits a steady gain in weight, is in good health, and is 4 to 6 weeks of age. An anesthetic consisting of ether vapor and oxygen is administered through an intra-pharyngeal or intratracheal tube. The height of the lip is carefully measured with calipers and markings for the pattern of the repair are made on the lip with sterile surgical ink. Incisions are made in the gingival buccal sulcus on each side of the defect and the soft tissues of the cheeks are freed widely so that there will be as little tension as possible on the sutures when the repair is finished. The alar carti-lages are undermined so that they will ro-tate upward and medially into a more normal position after the lip is closed. When the nasal septum is badly distorted an attempt is made to move and stabilize it in an upright position as near the mid-line as possible. The nasal base and muscu-lar layers of the lip are then closed using interrupted sutures of 5-0 chromic catgut. The buccal mucosa is closed with inter-rupted sutures of 5-0 plain catput while the skin and vermilion border are closed with
5-0 Nylon. The pattern tf the repair will vary considerably with each case and with the type of deformity which is present. Ex-amples of the various types of cleft lip and the results of their repair are shown in Figures 1 to 10.
Supportive Care
From the time of birth the infant with
a cleft lip should receive all feedings through a “cleft-lip feeder.” This is a 10 ml
Asepto syringe on the end of which is firmly attached a 1%-inch length of soft rubber catheter, The feeding is drawn into the
sur-- V
Fics. 1 and 2, A 6-week-old baby with a single incomplete cleft lip. Postoperative photograph, 8 months
after repair.
,‘c’
Fics. 9 and 10. A 6-week-old baby with a bilateral complete cleft lip. Postoperative photograph, 10 years after repair.
Fic. 11. Proper position for feeding a baby with a cleft lip. Note that the baby is held bolt up-right and that the arms are restrained to the sides.
ARTICLES 577
face of the tongue (Fig. 11). The mother is urged to apply constant pressure on the syringe bulb in order to feed the infant as rapidly as he will accept it; this will
prevent the infant from becoming overtired and falling asleep before receiving an
ade-quate intake. To minimize the ingestion of air, the infant must be held bolt-upright on the mother’s lap during the feeding and “bubbled” frequently. Scheduled rather
than self-regulated feeding is advised be-cause a portion of the early infancy must be spent on a regulated regimen while the
infant is in the hospital for repair of the lip; no special formula of food is required.
The baby is trained to sleep on the back or side and never on the stomach. This is to prevent rubbing of the face on the sheets and injuring or irritating the lip, either
be-fore or after surgery. The sleeves of the
jacket are pinned to the diapers so that the infant will become accustomed to the re-straint necessary during the repair and later during convalescence.
578
lip
while it is healing. The bow takes a slight amount of tension off the suture line but its chief purpose is to protect the lip from injury. Use of the cleft-lip feeder is resumed after operation. The exposed suture line is kept free of crusts by careful cleansing with sterile sponges soaked in normal saline solution before and after each feeding. The need for cleaning varies ac-cording to the quantity of food and mucuswhich is regurgitated through the nose. The Nylon sutures are removed on the third to fifth postoperative day. The lip guard is removed on the seventh postoperative day, and the infant is then ready for discharge from the hospital.
The mother is instructed to continue the use of the cleft-lip feeder until she returns at the end of a month for the first post-operative examination. She is cautioned again not to turn the baby onto the ab-domen and to continue to pin the sleeves of the jacket to the diapers in order to protect the repaired lip.
MANAGEMENT OF AN INFANT
WITH A CLEFT PALATE
Time and Method of Repair
The palatal cleft is repaired when the infant is approximately 14 months of age, when he has reached 9.9 kg (20 lb) in weight and is in satisfactory good health. After proper sedation the patient is anes-thetized by means of ether vapor blown through an oral hook or through an intra-tracheal tube. To create a fresh, raw surface for suturing, a very narrow sliver of tissue is removed from the edges of the cleft. Bi-lateral relaxing incisions are then made; these begin outside the alveolar ridge of the lower jaw, extend across the commissure between the upper and lower jaws and con-tinue inside the alveolar ridge of the max-illa to the level of the lateral incisors. Through these incisions the tissues of the soft and hard palate are carefully freed. The posterior palatine vessels are identified and stretched but they are not divided or ligated. The hamulus is isolated on each side and is fractured medially so as to lessen the lateral pull of the tensor palatine
muscles. The nasal fascia is cut transversely on each side. Extensive freeing and extreme gentleness in handling the tissues is vital to the success of a good repair. The palate is then closed in layers with interrupted simple and mattress sutures of 5-0 chromic catgut. It is essential that the palatal flaps be approximated without tension and that there be complete hemostasis. An effort is made to produce a long palate so that, with training, the muscular control will be good enough to effectively close off the
naso-pharynx from the oropharynx.
Supportive Care
The early management of an infant born with both cleft lip and cleft palate is the same as that outlined for one with cleft lip alone. The same procedures are appli-cable for an infant born with only a cleft of the palate; however, some infants in the latter group find feeding from the side of a cup or spoon more successful than from the cleft-lip feeder. Regardless of the type of defect, we prefer to establish a routine of feeding from cup and spoon by the age of 3 to 4 months. No nipple of any kind is
ever given to a patient with cleft palate. The palatal cleft usually decreases in width,
as each palatal shelf follows its normal
pat-tern of descent from the vertical to a more horizontal plane. Bottle feeding is dis-couraged because we feel that the use of a nipple prevents this descent, and conse-quently any possible decrease in the width of the cleft. Few infants have exhibited any difficulty in making the transition from a cleft-lip feeder to cup and spoon. It is noteworthy that these children rarely be-come habitual thumb suckers, but should
any tendency in this direction be exhibited, it is also discouraged for the same reasons that nipple feedings were avoided.
After the routine of cup-and-spoon feed-ing has been firmly established, the mother is requested to teach the baby to take the feeding from several different people; in this way, the infant does not become overly dependent upon the mother and will
ARTICLES
579
period before repair, he should be offered a large variety of clear fluids in addition to the regular diet. These include fruit or vegetable juices, broths, bouillons, carbo-nated soft drinks (which have been allowed
to go “flat”) and a great deal of water. When these suggestions are followed the child is more apt to have a peaceful post-operative period, during the first 3 weeks of which the diet is restricted to fluids.
For the first 5 postoperative days the pa-tient is fed clear fluids at 2-hourly intervals throughout the day and night; this helps to rinse and cleanse the palate of debris and mucus. Beginning on the sixth
post-operative day milk drinks are offered. Dur-ing the entire period of hospitalization and for 1 month after he returns home, the pa-tient must wear coaptation splints on the arms to prevent putting the fingers or any other objects in the mouth, These splints are not to be removed at any time unless the mother is close enough to restrain the child should he attempt to place anything in the mouth.
The hospital stay for the patient with cleft palate averages 9 to 10 days. For the first 10 days at home the diet is liquid; this is followed by 10 days of a soft-solid
diet, after which a regular diet may be re-sumed. Extremely hard foods and candies
are forbidden for at least 1 month follow-ing the operation. Special warning must be issued against sucking on straws or lolly-pops.
The patient returns for a surgical
exam-ination 1 month following discharge from the hospital, and is seen thereafter once a year until the surgeon no longer considers it necessary. This varies, depending upon the severity of the original defect and the need for counselling.
ADJUNCTIVE CARE
Speech Training
Speech development is discussed with the parent quite thoroughly, beginning in the period before the palate is repaired. The parents are advised not to encourage speech before the palatoplasty, but certainly they must not try to prevent it. One month
fol-lowing the operation they are instructed to begin active speech guidance. At least two
or three 15-minute periods are to be set aside daily when one of the parents reads to
the child, leafs through picture books
nam-ing the pictures, cutting out the pictures correctly identified by the child and putting
them in a scrapbook, etc. In order to teach
the child to direct the breath stream prop-erly and to help strengthen the palatal muscles, several periods are also to be set aside for blowing activities. These in-dude blowing a ping-pong ball across the table, trying to keep a feather aloft, blow-ing boats back and forth in a bathtub, the use of horns, whistles, harmonicas, etc. The parents are urged to speak clearly at all times, to talk to the child a great deal, and to read to him frequently. Any youngster must learn to listen actively to speech in
order to develop the ability to discriminate between sounds; he needs to be an integral member of the conversational groups at home. However, at no time should speech
be demanded or forced from him, nor
should it be made a point of dissension. The speech-training periods should be fun and should be anticipated with pleasure by the child and by the parents as well.
As speech progresses and as vocabulary
is built, the parents are advised to place special emphasis on words containing c, k, s, ch, and t. Standards for good speech must be set and maintained, but within reason-able limits. Blowing games should be con-tinued until the child is able to direct the breath stream through the mouth with ease.
When the child is 3 to 4 years of age, he is seen by the speech therapist to de-termine whether professional help is needed. If the youngster has normal intelli-gence and good auditory discrimination, and if the parents have provided a good speech environment, his speech, most likely, will be within the limits of normal.
Dental Care
The need for adequate dental care is most important for the child with a cleft
palate and cleft lip. In order to preserve
580
regular visits to the dentist should begin when the child is 3 years of age. He should start to use a small toothbrush at the age of 2 years. Because the teeth may be far out of alignment, they may not receive the natural cleansing action of the saliva, lips, cheek and tongue, and thus may develop caries more readily. Conscientious teeth brushing and the maintenance of good trition are essential features in the care of these youngsters. There is frequent need for later orthodontia, which is determined
by the dentist, the orthodontist or both.5
The Question of Tonsillectomy and Adenoidectomy
We do not advise removal of the tonsils,
and especially the adenoids, unless the child has chronic upper respiratory infec-tion or shows a loss of hearing. On rare oc-casions the tonsils may become enlarged to such an extent that they will actually hinder the free movement of the soft palate. Removal must be recommended or ap-proved by the plastic surgeon, and the op-eration should be done most carefully. We have found that children with normal, non-nasal speech all show remarkable activity of the lateral pharyngeal walls. Among the important muscles which create this ac-tivity are the palatopharyngei, which make up the posterior faucial pillars. Great care must be taken to minimize scarring of the pillars in order to preserve their mobility.
If adenoidectomy and tonsillectomy are necessary, the parents should be told that the child’s speech may be nasal in the im-mediate postoperative period, especially if the adenoids were large. Removal of these large masses from the nasopharynx pro-duces a larger nasopharyngeal vault with a greater velopharyngeal opening. Nasality
may persist until the child learns to make
the necessary muscular compensations. This may occur in a few days or it may take
a much longer period of time. If much nasality continues for more than 6 weeks, the child should be referred to a speech therapist.
Occasionally it is necessary to remove
excessively enlarged tonsils or adenoids during the child’s first year, before the time of palatoplasty. Some surgeons feel that this should be done routinely in patients with cleft palate; we have no evidence to sup-port a firm stand on either side of this ques-tion, We do advise that these children be kept as free as possible from upper respira-tory infections and that the ears be ex-amined frequently whenever the lymphoid tissue becomes excessively enlarged.
EVALUATION OF THE CLEFT-PALATE
PROGRAM
In an effort to determine the validity of
our clinical observations, an evaluation of the long range results of our cleft-palate program was undertaken in 1954-1955. The details of this study have been reported elsewhere and will be merely summarized here. Two groups of children, totalling 164, were chosen for detailed evaluation of the palatal closures. Fifty-six represented a con-secutive series operated upon in 1946 and 1947. The remaining children (108) were selected because of their good speech and availability for extensive examination and
study. The average age of the entire group
at the time of this study was 8 years; the average age at operation had been 19 months. All were operated on by the same surgeon; all were primary one-stage clos-ures.
The following data were obtained on each patient:
1. Age.
2. Sex.
3. Family history. 4. Type of defect.
5. Age at time of lip repair. 6. Age at time of palate repair.
7. Preoperative adequacy of tissue, width
of cleft, presence or absence of micrognathia,
etc.
8. Time of onset of speech; description of
postoperative speech.
9. Analysis of present speech, including a
tape recording for each child.
ARTICLES 581
12. Presence of Passavant’s ridge and/or lateral pharyngeal activity.
13. Audiometric evaluation.
14. ENT status; time of T&A and any post-operative nasality thereafter.
15. Cephalometric roentgenographic ex-amination.
16. Occlusal evaluation by casts and
intra-oral roentgenograms.
17. Orthodontic intervention, time and
amount of treatment,
18. Estimate of child’s intelligence and gen-eral adjustment.
19. Estimate of adequacy of home environ-ment.
The criteria of a successful repair of a cleft palate cannot be based solely on ob-servation of palatal closure or an cranio-facial measurements. The palate should be anatomically closed and cephalometric evaluation should show normal facial de-velopment. Even more important, however, the child must be of acceptable appearance, must speak within the limits of “normal” speech and must be as well adjusted to his environment as his contemporaries.
To check the authors’ judgment of “normal” speech, a tape recording was made containing the voices of 20 children all of whom repeated the same group of 10 to 12 sentences chosen to illustrate par ticularly the sibilants (s, z, sh, zh) and the plosive consonants (k, g, t, d, p, b, tch, dge). Some had repaired cleft palates and some were normal children. The tape-recording was presented as a test on three separate occasions to the Surgical Staff of the Chil-dren’s Medical Center, to a graduate semi-nar in Speech Pathology at Boston
Univer-sity and to the members of the New
Eng-land Pediatric Society. The listeners were requested to identify the children with re-paired cleft palates. In each test the great majority of judges could not pick out the patients who had had cleft palate repaired and all agreed that the speech of every child on the tape fell within the range of normal.
The positive findings may be summarized briefly: Of the entire group of children studied, 130 (79%) spoke with no nasality
and of this number, 116 (90%) had no speech therapy other than that given by way of parental guidance. The others were helped for a short while in the preschool period by a speech therapist. Only 19% of the entire
group had significant hearing loss (20 deci-bels or more in the better ear). The ex-pected figure for children with cleft palate
who have hearing loss generally is at least
25% or more, while the expected figure for the overall school population is about 15%.
No significant correlation was found
be-tween the physical production of good speech or hearing loss and the type of origi-nal cleft or velar length. Facial patterns as determined by cephalometric evaluation were different from ideal normals, but did not differ appreciably from the pattern of
a random sample of the normal local popu-lation. In general the majority of the chil-dren studied were able to fulfill the criteria of a successful repair.
Obviously, the best results cannot be ob-tamed without the collaboration of the sur-geon, speech therapist, dentist, orthodon-tist, family doctor or pediatrician, possibly the otolaryngologist, and certainly the par-ents. In some clinics the “team” is enlarged
to include as well a prosthodontist, a
psy-chologist and a social worker. The “unsung heroes” on every team, however, are the parents. Their diligence in maintaining high standards of infant care at home and their perseverance through each phase of adjunc-tive care is of utmost importance in contrib-uting to a successful result. In order to help them understand the total picture and the importance of their role we have provided the information they are most likely to need in pamphlet form. N’Iuch of the detail in-cluded is also helpful to the child’s pediatri-cian and provides him with a “timetable of treatment” that we have found to be
prac-tical.3,8
SUMMARY
Although some aspects of the manage-ment of a child with a cleft lip or cleft
palate or both are controversial, it is
582 PEDIATRICS OCTOBER 1957
of these youngsters involves the co-operation
of a multi-professional group including at
least a surgeon, dentist, speech therapist,
pediatrician, orthodontist, and the parents as well. It is not necessary for the group to be centralized in location, although this is
helpful to the patient. However, each
mem-ber of a group must be aware of the po-tentialities and procedures of the other
members and should have a knowledge of the terminology and basic principles of the other disciplines represented. As his duties of total care are ever present and continu-ous, the pediatrician is in a strategic posi-tion to help the parents to understand and to implement the consecutive phases of therapy in the home.
The rationale and a general description of one type of cleft lip-cleft palate pro-gram as it is carried out at the Children’s Medical Center in Boston is presented. During the last 15 years, 2,635 operations for closure of the lip and palate have been performed in the Plastic Surgery Unit. The
authors’ policy is to repair a cleft lip at
6 to 8 weeks of age and to repair the palate within the first 2 years of life, preferably
at about 14 months of age.
Included is a summary of a study made at this Center to evaluate the long-range
results of early palatal closure and over-all care of a group of 164 children operated upon between the years of 1942 and 1952.
The conclusions of this study corroborate the authors’ previous clinical impression that the results of early palatal closure have been so satisfactory that continuation of the policy seems warranted.
Supportive care is described in some de-tail because of the authors’ wish to em-phasize its importance and to provide for the pediatrician a practical guide which long experience has proven to be successful.
REFERENCES
1. Graber, T. M.: Changing philosophies in cleft palate management. Doctoral dis-sertation, Northwestern University Dental School, 1948.
2. Slaughter, W. B., and Brodie, A. C.: Facial clefts and their surgical management in
view of recent research. Plast. & Recon-struct. Surg., 4:311 , 1949.
3. MacCollum, D. W., and Richardson, S. 0.: Harelip and cleft palate. Your Child’s
Health, Children’s Medical Center,
Boston, Mass., Series 7, 1954.
4. MacCollum, D. W., Richardson, S. 0., and Swanson, L. T. : Habilitation of the cleft-palate patient. New England
J.
Med., 254:299, 1956.5. Swanson, L. T., MacCollum, D. W., and Richardson, S. 0. : Evaluation of dental problems in the cleft palate patient. Am.
J.
Orthodont., 42:749, 1956.6. Cannon, B., Fisher, D., and Britton, H. C.:
Plastic surgery; harelip and cleft palate. New England
J.
Med., 245:215, 1951.7. Gaines, F. P. : Frequency and effect of hear-ing losses in cleft palate cases.
J.
Speech Disorders, 5:144, 1940.8. Richardson, S. 0. : Pediatric aspects of cleft palate habilitation. Paper read before the Am. Association for Cleft Palate
Rehabili-tation, St. Louis, Missouri, April, 1952.
SUMMARIO IN INTERLINGUA
Tractamento
del
Fatiente
con
Cheilo-Palatoschisis
Ben que certe aspectos del tractamento de
pueros e pueras con cheiloschisis o palatoschisis 0 ambes es controverse, on es generalmente de accordo que le optime procedimento require le
cooperation de un gruppo multiprofessional, in-cluse al minus un chirurgo, un dentista, un therapeuta del parola, un pediatro, un
ortho-dontista, e etiam le parentes. Ii es importante que omne membro de un tal gruppo es conscie
del potentialitates e del programma del altere membros e que ille cognosce le terminologia e le principios fundamental de omne he dis-ciplinas involvite. Proque le pediatro ha le deber de un semper presente e continue
surveliantia total, ille se trova in un position strategic pro assister le parentes in br corn-prension del situation e in br effortio a activar
be phases consecutive del therapia al domicilio.
Le objectivo del presente articubo es
pre-sentar le theoria insimul con un description general del practica del typo de programma
pro be tractarnento de casos de cheilo-pala-toschisis que ha essite adoptate ab Centro Me-dical pro Juveniles a Boston. Durante le passate
ARTICLES 583
Le reparo de labios findite es effectuate quando be patientes ha 6 a 8 septimanas de etate.
Reparo de palato findite se face durante le 2
prime annos del vita, preferibilemente al etate
de 14 menses. Le mortahitate esseva zero durante le mentionate 15 annos (e etiam
du-rante un certe periodo de tempore precedente). Es presentate un description detaliate del tractamento chirurgic e del mesuras adjunctive in casos de cheibo- e palatoschisis. Es sublineate be aspectos importante in be tractamento sup-portative, incluse le maniera e methodo del alimentation, be mesuras immediatemente pre-e postoppre-eratori, e be routine a bonge vista pro be correcte habilitation del patientes.
Es includite in be articubo le summario de un studio executate a iste cinica pro evalutar be resultatos a bonge vista de precoce clausura palatal e del manipulation general de
gruppo de 164 pueros e pueras qui esseva ope-rate inter 1942 e 1952. Le conclusiones de iste studio corrobora be previe impression clinic
que be resubtatos de precoce clausura palatal es
successose si iste mesura es combinate con un
programma diligente de therapia dental e de therapia del parola e es supportate per be co-operation del parentes. Mesurationes
cranio-facial non revelava appreciabile deviationes ab un gruppo de 25 normal subjectos de controbo.
Septanta-nove pro cento del gruppo studiate
habeva nulle nasalitate de enunciation, ben que
90 pro cento de iste numero habeva recipite nulbe therapia del paroba a parte le guidamento del parentes.
De facto, be plano total de tractamento es considerate como si satisfacente que be
con-tinuation del politica hic delineate pare
justi-ficate.
Tm RESPONSE OF RHEUMATIC AND NON-RHEUMATIC CHILDREN TO STREPTOLYSIN 0
CONCENTRATE, R. W. Quinn. (J. Chin. Invest., 36:793, June, 1957.)
