ment, it is evident the discomfort and anxiety that must arise will be very much lessened.

Sponge or leather* is sometimes used for this purpose, but is on many accounts very objectionable, from becoming sour and offensive after use, while the vulcanized rubber can be kept perfectly sweet and wholesome by means of washing in warm water.

Under the most favourable circumstances, and when the greatest possible care is exercised, there is little doubt that the growth and development of the child is very much retarded, though its constitution may not ultimately suffer in consequence of the defective palate, beyond that delicacy of frame which is very often the accompaniment of extreme parental anxiety and watchfulness.

The time for operating upon the hare-lip will have to depend upon the state of health of the babe, and may take place a few hours or several months after birth, according to circumstances. This is a matter exclusively in the hands of the surgeon, and quite beyond our province to enter into, except in reference to one or two points which, with all deference, we would submit to the consideration of those gentlemen who are in the habit of performing the operation.

When the division in the lip is bilateral, and the intermaxillary portion of the jaw very pro* Snell, on "Artificial Palates." 1828.

minent apparently, it is usual in a large number of cases to remove the protuberance altogether, using the middle portion of the lip for the columnæ nasi, and then, having pared the edges of the side-flaps, to bring them together in the median line.

The result of this treatment in after-life is to give to the upper lip an exceedingly flat unsightly appearance, and to the lower lip a relaxed and pouting expression.

In

If the patient's face be looked at from the side, the contour of the countenance would seem to indicate that only a portion and not the whole of the intermaxillary process should have been removed, since its apparent prominence was undoubtedly due principally to the great want of substance on each side, and not alone to an excessive development in the median portion. Sir William Fergusson's recent work "On the Progress of Anatomy and Surgery during the last Century" this is suggested as a reason, and drawings given of a case, by which it is proved how little deformity need occur when the patient is in the hands of a skilful operator. In the same chapter it is also pointed out that the notch in the lip, so often observed in after-life, is mainly owing to the edges of the divided lip not being cut away to a sufficient extent, so as to bring the skin and mucous membrane into proper contact with each other. We shall have occasion to

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remark in the sixth chapter of this volume on the trouble arising from the neglect of this apparently trivial matter. During infancy but little difference is observable in the tone of the babe's cry, but when the time arrives at which the child should, under ordinary circumstances, begin to give utterance to "articulate" sounds, it becomes apparent how great a change the deformity gives rise to in the voice.

In many cases no amount of attention, except a mother's instinct, will be able to understand what the child attempts to express; and this, strange to say, is not regulated, as might be expected, by the extent of the cleft, but is almost as bad in simple division of the soft palate as in those cases where there is also division of the hard palate and alveolus.

From birth up to seven or eight years of age the cleft increases both in width and length, in proportion to the rest of the mouth, unless, in the case of hare-lip being associated with it, there are mechanical means used to compress the parts laterally, by the use of a truss, such as we find described in the work by Sir William Fergusson already referred to. The gap may then be reduced so that at the anterior part, the two sides of the divided alveolus will become so closely approximated as to appear continuous. After the age we have mentioned we are led to

the conclusion, so far as our own opportunity of observation has gone, that the cleft simply increases in length, the width being, in the majority of cases, the same at twenty-one years of age as at the earlier period.

From seven to ten years of age the patient will become first conscious and sensitive of his or her defective speech. At this age, too, nourishing food properly masticated is of great importance. Both these circumstances, therefore, would seem to point to it as the best time for the insertion of an artificial velum, unless the operation of staphyloraphy has been performed during infancy;* for it will be well-nigh impossible in a case of clert in the hard and soft palate to apply the food with the tongue to the roof of the mouth in such a way as to ascertain when it is ready for swallowing. The consequence will therefore be that a considerable quantity of that which should yield the most nutriment is received into the stomach in such a state as to impair the digestive organs. There is also the liability during childhood of the cleft getting filled up with the solid food, and in some cases causing suffocation.

The difficulty of controlling the passage of air through the nares by means of the velum palati

* It should be remembered, however, that this operation has been so recently introduced that we have no means of judging what its effect will be when the patient arrives at adult years.

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in nearly all cases gives rise to a most pernicious habit of checking it by means of a contraction of the alæ of the nose through the influence of the compressor naris muscles; thus to a certain degree rendering the utterance more distinct, though it gives a very disagreeable "nasal twang." It is wonderful to what an extent these muscles come under the patient's control. In the French language this would be of no consequence; in the Anglo-Saxon tongue, however, it is a considerable annoyance, and most difficult, when firmly established, to overcome. Still, if an artificial palate be inserted at the time we have indicated, it may be prevented or checked to a very great extent, until the habit is entirely forgotten or overcome by the patient finding it is unnecessary to control the passage of air through the nostrils, except by the means now provided in the elastic velum.

From the great exposure of the nares and fauces to the air in large perforations or clefts of the palate, these parts are exceedingly liable to inflammation and ulceration extending downwards, and during the winter months causing frequent sore-throat and deafness, as well as loss of voice. Considerable irritation arises in the cavity of the nose from the mucus drying on the turbinated bones and margins of the opening, in consequence of the too free access of air to these