sound from the larynx might escape through both mouth and

nose.

But, for the performance of these functions, it must be free from perforation or fissure, and must be of such length that when elevated it will meet the pharyngeal wall.

If a natural velum does not meet this last requirement, it represents a valve which has been cut off at its free margin, and is no longer capable of performing its functions by reason of the escape. Such a natural velum would be as incapable of producing perfect articulate speech as if it were fissured, perforated, or in any other way made defective.

Articulate speech is also dependent in its perfection upon the activity of the pharyngeal muscles.

The closing of the posterior nares is not dependent alone upon the elevation of the velum-palate, but in a large measure the closure is due to the advancement of the pharyngeal wall to meet the border of the palate.

In no work on the mechanism of speech with which the writer is acquainted is this important function of the constrictor muscles of the pharynx fully recognized.

It is an important organ of speech in normal articulation, and in the effort to articulate with abnormal organs it develops an activity and a power at times truly wonderful. So much so that, in some cases in the writer's practice, it (the superior constrictor of the pharynx, in conjunction with the tongue, in cases of the absence of the palate) has enabled the patient to make all the sounds which in normal articulation are dependent upon the integrity of the palate.

The failure of surgery has not been in the inability to bring the edges of the divided velum together and get a union, but it has been in the one respect before pointed out, viz., that the newly formed palate as the result of staphyloraphy is always too short at its posterior edge-does not reach the pharynx, can not be made to, and the speech will nǝcessarily and always be defective, save in some extraordinary cases. As an operation it is with no small degree of pride that the surgeon may view the result of his work in seeing a complete union throughout the entire length of the fissure, including the uvula, and apparently a normal septum

where before was a gaping orifice, and thus he may lose sight of

First, the fact that this new palate has very little muscular power as compared with a normal organ, owing to the injury which the muscles have received in the operation, and—

Second, that it is defective in dimensions because there never was tissue enough to make a velum which would bridge the chasm in both its breadth and length.

The origin of the fissure was in a lack of a development of sufficient material to come together and make a perfect septum, and no division of the muscles or stretching of the tissues subsequently will make up for this developmental deficiency.

It has been also claimed that the operation was not only valueless, but productive of positive harm from the fact that it produced at best a rigid curtain which served to split the column of sound in its upward ascent, and render it less manageable than it was before; that in early life the patient had acquired a certain control over the voice and a measure of articulation which the non-elastic and immovable curtain deprived him of.

In this connection I am reminded of a case shown me by Mr. Pollock, F. R. C. S., in St. George's Hospital, London, some years ago, where Mr. Pollock had performed just twelve months before a very beautiful operation for fissured palate, and the result was a complete union, including the uvula.

As a test of the result, I handed the patient a newspaper and requested him to read to us, which he did. Not understanding him myself, I turned to Mr. Pollock, and asked him if he did. He replied, "No, not a word. I did not before I operated, and I do not now."

The contrasted results of surgery and mechanism are fully shown in the following described case.

In 1866 there came to me a lady about twenty-five years of age, with congenital fissure of the palate, which had been operated upon about ten years before by Dr. Hulihen, of Wheeling, Virginia.

The fissure of the velum was complicated with an extensive separation of the maxillæ, following the line of the intermaxillary suture on the right side, dividing the alveolar arch

and also the lip. The lip had been operated on in early life. At sixteen years of age staphyloraphy was performed most successfully. The soft palate was united along its entire length, including the uvula.

Fig. 1 is copied from a plaster cast taken at the time she

came into my hands. In it are shown the fissure of the hard palate and division of the alveolar border, together with the united velum; even the marks of the sutures are distinctly visible in the cast.

For the ten years succeeding the surgical operation the patient had worn an obturator which closed the remaining opening. It was skillfully adjusted, and gave her all the benefit that it was possible to obtain from an obturator alone.* But with ten years of application and an intelligence equal to the undertaking, she was unable to articulate with any more distinctness than before the operation. The father said, "If anything, she does not speak as well."

*The writer makes a marked distinction between an obturator and an artificial velum or palate. An obturator is a plug or cover to stop an opening, applicable to perforations of the hard palate, and when in use is immovable. An artificial velum is of a different nature, being applicable only to lesions of the velum, and is generally flexible and under the control of the adjoining muscles.

There was very little mobility to the palate, and from the closest calculation there was a space of half an inch in breadth behind the velum, even when the pharyngeal wall was contracted toward it.

Through this space there was a constant escape of the voice. Nearly all the vowels were nasalized; g, k, d, 8, and ch she could not make, owing to such escape.

There was apparently but one solution to the problem, which was to make an artificial extension of the palate to enable it to meet the pharyngeal wall, and thus cut off at times the communication with the nasal cavity. The appliance consisted of an obturator not very unlike the former one, filling the anterior gap, and carrying with it some artificial teeth to supply the loss of some natural ones; and attached to its posterior extremity an extension of elastic rubber, following down the superior surface of the palate to its posterior border and beyond to meet the pharyngeal wall.

This apparatus is shown in Fig. 2, and in Fig. 3 it is also seen in situ.

Letter A shows the obturator, B the elastic extension, and C the apron or palate, occupying the space in the pharynx. The same letters apply to both illustrations.

This instrument was introduced by folding the elastic extremity together, grasping it with a pair of tweezers, and passing it through the opening in the hard palate, when it would find its natural position on the introduction of the obturator. Subsequently the patient would carry the palate through the opening with the tip of the tongue alone.

It created no irritation in the pharynx, and was worn with entire comfort.

The only immediate change was in the tone of voice. The vowels and some other sounds were less nasalized.

By my advice she went under the training of Professor Peabody, an elocutionist, and in a few weeks showed very marked change. She acquired the ability to articulate with perfect distinctness every sound of the English language, and in reading, with care on her part, would enunciate every word and syllable without fault.

Thirteen years have now passed, and the few teeth then remaining have succumbed to the influences which destroyed their fellows, and not a natural tooth remains in the mouth. Within the past year the obturator here described has been substituted by another bearing an entire upper set of artificial teeth, and the entire apparatus is worn with as much freedom as its predecessor, which was attached to the natural teeth. The speech has not degenerated, but rather improved in

ease.

The interest in this case lies

1st. In the remarkable success attending the surgical operation where the fissure was of such extreme width.

2d. In its complete failure to improve the speech or produce any other beneficent result.