THE FORM USED TO THE PRESENT TIME.

277

artificial velum, which fulfills the functions that this one does; nor do I believe it possible to make a flexible, yielding instrument, which shall be of so universal application, in any other form or by any other method.

19

CHAPTER XII.

TREATMENT OF CONGENITAL FISSURE OF THE PALATE.

The

CONGENITAL fissure of the palate presents far greater difficulties to be overcome than cases of accidental lesion. opening is commonly more extensive, the appliance more complicated, and the result more problematical. Nevertheless, appliances have been made in a large number of cases which have enabled the wearers to articulate with entire distinctness, so much so as not in the least to betray the defect. Most of the earlier efforts in this direction were merely obturators-plugs to close the posterior nares; and the results were far from satisfactory.

A reference to the history of obturators and of artificial vela will show the ingenuity of some of these contrivances. It was not until it was recognized that the two classes of cases, accidental and congenital, were entirely distinct that much progress was made. Nearly every case of acquired lesion can be treated by an obturator with success; but rarely will an obturator be of benefit in a congenital fissure, even if the congenital and accidental lesion present substantially the same form of opening. The character of the different classes has been constantly confounded in the discussions upon the subject, and an instrument admirably adapted to one class has had claimed for it an equal application to the other class.

It should be understood, therefore, as a rule to which there will be few exceptions, that congenital fissure of the soft palate requires for its successful remedy a soft, elastic,

THE ESSENTIAL REQUISITES OF AN ARTIFICIAL VELUM. 279

and movable appliance; and that, with the most skillfully made instrument, vocal articulation must be learned like other accomplishment.

any

The various inventions for this purpose are described under the "History of Artificial Vela." The Stearn instrument, with all its complexity, embodied the true principle, viz., the rendering available the muscles of the natural palate to control the movements of the artificial palate. To Snell is possibly due the credit of having first recognized

this principle, but his description is so defective as to leave the matter in doubt.

The essential requisite of an artificial velum is to replace, as far as possible, the natural form of the defective organs with such material as shall restore their functions. Muscular power certainly can not be given to a piece of mechanism, but the material and form may be such that it will yield to, and be under the control of, the muscles surrounding it, and thus measurably bestow upon it the function of the organ which it represents.

In the discussion of the failure of staphyloraphy on page

280

SUPERIOR SURFACE OF AN ARTIFICIAL PALATE.

211, and in the chapter on "Mechanism of Speech," the necessity for the separation of the buccal and nasal cavities in perfect articulate speech is clearly set forth. Therefore, every artificial palate-whether elastic or non-elastic, of the character of a velum or an obturator-must be so arranged that the pharynx can be at times completely closed.

Fig. 193 represents a model of a fissured palate, complicated with hare-lip on the left of the median line. There is also a division of the maxilla and the alveolar process; the sides, being covered with mucous membrane, lie in contact with each other, but they are not united. If desirable for any reason, a simple surgical operation can be performed, which will unite both hard and soft tissues at this point of

division. The left lateral incisor and left canine tooth are missing-whether extracted or undeveloped was unknown. Fig. 194 represents the artificial velum, as viewed upon its superior surface, together with the attachment of a plate containing a clasp and two artificial teeth to fill the vacancy. The lettered portion of this appliance is made of elastic vulcanized rubber, to which the velum is connected by a stout gold pin, firmly imbedded at one end in the hard-rubber plate. The other end has a head marked C, which being considerably larger than the pin and than the corresponding hole in the velum, it is forced through-the elasticity of the velum permitting-and the two are securely connected. The process B laps over the superior surface of the maxilla (the floor of the nares), and effectually prevents all inclination to

INFERIOR SURFACE OF AN ARTIFICIAL PALATE. 281

droop. The wings A A reach across the pharynx, behind the remnant of the natural velum and bifurcated uvula. The wings DD rest upon the opposite or anterior surface of the soft palate.

Fig. 195 represents a model, the same as Fig. 193, with the appliance shown in Fig. 194 in situ; the wing D D, in Fig. 194, and the posterior end of the artificial velum A, alone being visible in this figure. The reader will bear in mind that the essential characteristics of this appliance are a

soft, elastic substance filling the gap in the soft palate, with a flap behind as well as before, which enables it to follow all movements of the muscles with which it comes in contact, and thus perform to a very considerable degree the function of the fully developed natural organ.

Figs. 191 and 193 represent two cases of remarkably general likeness, although they differ twenty years in age and more than five years in the period of time at which they were treated. The palate placed in situ in Fig. 191 shows an instrument which, with variations in size, is of almost universal application. It is nearly identical with the palate