force; this movement, it is evident, can only be effected by two muscles, the levator palati and palato-pharyngeus. These muscles, then, I consider the chief mechanical obstacles to the junction of the margins in the mesial line. Hitherto I have taken no notice of the action of the circumflexus, or tensor palati. I am inclined to think that its action is very limited, and probably, as the dissection in my possession would indicate, is greater upon the parts outside the posterior pillar than on those contiguous to the fissure. Neither have I alluded specially to the action of the palato-glossus, because, though it might with a feeble power incline the soft palate downwards, its influence, as regards the practical view I am now taking, is completely counteracted by the more powerful muscles connected with the palate above." There can be no doubt that the plan suggested in the concluding portion of this paper by Sir William Fergusson, of dividing the levator palati, palato-pharyngeus, and palato-glossus muscles, is by far the most scientific and certain way of proceeding in order to get an easy approximation of the margins of the cleft; and in the recent lectures on the "Progress of Anatomy and Surgery during the Present Century," delivered at the Royal College of Surgeons, the number of cases (between 300 and 400) which that gentleman has treated clearly show the soundness of the views which he put forward in 1844. There seems, however, one important point that has been almost entirely overlooked, that is, the deformity which invariably exists above and behind the soft palate, in consequence of which the upper part of the pharynx entirely loses its dome-like form, the ends of the turbinated bones being exposed to view, and the posterior openings to the nares absent.* When, therefore, the palate which has been subjected to a surgical operation is brought into play, the parts would seem to be perfect, and much dissatisfaction is felt at the disagreeable tone of the voice, often forming a matter of surprise both to patient and operator. There can be little question that in very many of these cases this has arisen from the free communication that exists between the upper part of the pharynx and the cavity of the nose, even when they are separated from the mouth partially or completely by the now perfect velum palati. All the skill of the surgeon would, we fear, fail to restore the posterior nares to their natural condition, and yet it is tolerably clear that we cannot expect to get a natural tone of voice, * Passévant relates a case in which he attached the uvula (after the cleft had been closed) to the back of the pharynx, in order to improve the voice; but the practice does not seem to have become at all general. accompanied by intelligible articulation, unless something can be done either surgically or mechanically to represent the parts that have been undeveloped in the cavity of the nose and pharynx. When the cleft extends into the hard palate to any extent, the septum of the interior of the nose will be found incomplete, as in fig. 15, page 54; and where the cleft is unsymmetrical, the margin of the gap in the anterior portion will be seen articulating with the vomer very often. Since the propagation of clear and agreeable sound is dependent to such a degree for its modification on the shape of the passages through which it travels, the importance of considering the nasal region in the treatment of congenital cleft palate cannot be overlooked. CHAPTER III. ON THE TROUBLES ARISING FROM CONGENITAL CLEFT OF THE PALATE. DIFFICULTY OF SUCKLING DURING INFANCY. RETARDED DEVELOPMENT OF THE BODY FROM INSUFFICIENCY OF NUTRIMENT. SPEECH. DEFECTIVE INFLAMED STATE OF NARES FAUCES, ETC. AND WHEN a child is born with hare-lip, the attention of the medical practitioner or nurse will be at once attracted, and an examination made of the mouth to ascertain whether it is complicated with cleft palate. If, however, there is no deformity of the lips, the simple cleft may not be observed until the child begins suckling; if it is small, and confined to bifurcation of the uvula, this will not cause much trouble; but should it extend through the soft palate into the hard, the milk will be found oozing from the nose instead of passing from the mouth into the stomach in the normal manner. Under these circumstances, the child will have to depend for its support upon the nourishment that can be administered to it by means of a spoon or feeding-bottle. The latter is the better course fo the two undoubtedly, and the little patient may be very much helped in the process of receiving its food by means of the artificial nipple and tubing attached to Maw's very simple but efficient feeder if a little contrivance shown in the accompanying woodcut be attached to the neck of the mouthpiece. FIG. 4. The palate-piece alone and FIG. 5 attached to the ordinary nipple sold with Maw's infant-feeder. This consists simply of a flap of elastic indiarubber made to fit into the roof of the mouth. The pressure of the nipple against its surface when in position will thus convert it into an artificial palate-piece, and prevent the escape of the milk into the nose in the effort of swallowing. It was suggested some years back that a flap of thin sheet elastic, not modelled to the arch of the palate, but simply cut out and sewn on to the feeder should be used; when it is not convenient to obtain such a one as we have just described this is a very good expedient, but when it is possible to procure a properly-fashioned arrange |