condition, and much satisfaction was afforded by the improvement in a very short time, not only in the facility with which the patient could make herself understood, but also in the tone of the voice, which was unquestionably owing to the alterations that had been produced in the form of the superior part of the pharynx.

Up to the present time the progress in this case has been steady and satisfactory.

CASE V.-Mr. R; æt. 22; cleft of the soft palate, extending just beyond the posterior margin of the hard palate; treated May, 1864.— The voice in this case was very bad. The young gentleman was most anxious to have something done, as a public appointment was being kept for him, provided his speech could be rendered intelligible. A velum was made fitting into the cleft, but, unlike the others shown, it had only one flap at the posterior part, the two sides of the cleft embracing it only to the commencement of the bulbous portion of the bifurcated uvula. Though this extremely simple form of instrument was used, the result was such that in two months he was able to enter upon the duties of the appointment that had been held open for him.

The elastic rubber piece was of course held forward in position in the usual way :

CASE VI.-Mr. B

; at. 15; fair com

plexion, nervous temperament; cleft of hard and soft palate, the division extending through the maxillary bones, with an opening from the nostril to the mouth between the lip and the labial surface of the alveolus, the operation for hare-lip having been performed during infancy.

-This young gentleman's speech was so exceedingly defective that he could only commmunicate with strangers by means of writing, while those who were well acquainted with him had to pay the greatest attention to understand what he attempted to say.

The mouth was treated (being very similar in form) in nearly the same way as Case No. 3, with the addition of a process (if we may apply an anatomical term to such a purpose) to run forward into the left nostril to prevent the passage of air between the front of the mouth and nose in the utterance of the explosive sounds, when the lips are firmly compressed, and the air for a moment requires confinement in the cavity of the mouth. This case proceeded very satisfactorily, the voice and speech improving in a very short time, the health also being benefitted from the greater care with which the food was prepared for swallowing.

F 2

CHAPTER VIII.

SIX CASES OF THE SECOND CLASS OF DEFORMITIES

THOSE ARISING FROM ACCIDENTAL

TREATED BY MECHANICAL MEANS.

S

CAUSES

CASE I.-Sophia S―; æt.32.-Applied at the Hospital for Diseases of the Throat for treatment of severe ulceration and loss of parts at the back of the mouth. Nearly the whole of the velum palati had disappeared, the anterior and posterior pillars of the fauces were likewise destroyed, so that the roof of the mouth presented the appearance of continuance backwards to the posterior wall of the pharynx. In the position that would be occupied by the uvula and central portion of the soft palate, when elevated for dividing the mouth from the nose, there was a large opening of an oval form, about one and a quarter of an inch in extent one way, and three-quarters of an inch from side to side. In swallowing, there was not the slightest movement at the back of the mouth, except in the tongue, which was the only member that could contribute any assistance to the process of conveying the food to the opening into the œsophagus. The back of the mouth was in

this way kept in a very irritable condition by the continual lodgment of food in the cleft. From the state of the palate, speech was scarcely intelligible, and the life of the poor woman was in every way a matter of considerable discomfort. Owing also to the great induration of the parts on each side, where the indications of the anterior pillars of the fauces were apparent, we concluded that no power could be obtained to work an elastic velum with any service or comfort, while at the same time there was the consideration to be borne in mind that the disease was still going on, and it was desirable rather to protect the parts from the irritation resulting from food, &c., than to increase the trouble by having an artificial velum, that must necessarily produce some chafing, the mucous membrane being so exceedingly sensitive. A simple hard rubber obturator was therefore made, partially closing the aperture, and having the inner surface highly polished. This has been very satisfactory in its results.

CASE II.-William T—, engineer; æt. 37.— In this case the upper maxillary bone was destroyed on the left side from the central tooth to the second molar tooth, following the line of the intermaxillary suture, and the connection of the palate-bone with the upper maxilla. The septum of the nose was quite perfect, articulating with the maxillary bone of the opposite side.

The turbinated bones of the left side, with the walls of the antrum, were entirely destroyed up to the floor of the orbit, leaving a gap for restoration by artificial means of considerable extent. The voice was very imperfect, mastication and swallowing very difficult. The appearance of the case is shown in fig. 31.

The instrument that was constructed to remedy these defects is shown complete, ready for wear, in fig. 32; also with the parts separated, showing how far the hard rubber extended, and where the elastic india-rubber was connected with it, in order that the more delicate parts might not be irritated.