282 SIMPLICITY AND ORIGINALITY OF THIS APPLIANCE.

shown in Fig. 194, were that one cut across the middle. Like the other, it is made of soft rubber, and, moreover, it will need an additional fixture to fill the gap in the hard palate, and also to keep the artificial velum from being swallowed. In Fig. 194 there is a projection marked B, which is made of soft rubber, and is intended to assist in supporting the velum in position. This is not always necessary or desirable; there are cases where the velum is quite as well sustained without this projection, and where, if it were applied, it would injure the tone of the voice by clogging the nasal passage.

In the case Fig. 191, if support were desired by lapping on the floor of the nares, toward the apex of the fissure, it would form a portion of the hard palate or obturator, instead of being part of the velum or soft palate, as in the other. It was to produce this effect by a simple appliance that the writer labored unremittingly for more than ten years; the appliance of to-day being no modification in any sense of that of any other author, but an individual and separate invention, entirely unlike anything which preceded it, and so simple that we can conceive of no different way by which perfection of result can be so nearly attained. Hundreds of instruments of like character, now being successfully worn, attest the writer's confidence in it.

Simplicity has gone but one step further, and that has been to leave off entirely the posterior flap marked A A in Fig. 194. This has been done in England, France, and Germany, and occasionally in this country, and a parade made of the fact, as an improvement on the invention of the writer; but the experience of the past shows that in all these cases the makers have failed to comprehend the requirements of the case, and have, in attempting to improve the instrument, dispensed with one of its essential characteristics.

The latest invention, and one which the author believes to be of almost universal application, is represented in Fig. 196. To appreciate the importance of this invention, it must be

THE AUTHOR'S LATEST INVENTION.

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borne in mind that heretofore an instrument peculiar in form has been required for every separate case. Each appliance, being made in a mold of special adaptation, has therefore entailed upon the operator a large amount of labor. With this later invention, it is believed that with a series of molds, producing a limited variety of palates adapted to the leading features in such cases, nearly every case of congenital cleft can be provided for, upon the same principle as other forms of surgical appliances made for general use.

It was only after years of experience, and the observation of many cases, that the characteristics which were common to all could be determined. Those common features are as follows: a. The fissure through the soft palate is always in the median line. b. The variations, if any, from the median line, are anterior to the soft palate in the palatine and maxillary bones. c. Thickness of the border of the fissure in the remnant of the soft palate is generally uniform. d. The sides correspond very nearly with each other in length, breadth, thickness, and contour. e. The chief variation in nearly all clefts of the soft palate is in

284

AN UNIVERSAL ARTIFICIAL PALATE.

their size or breadth, and this is true without any reference as to whether the fissure extends forward into the hard palate or not.

In the author's practice a series of a hundred molds, representing as many variations in size, provides for nearly every emergency; Figs. 197 and 198 illustrate the extremes. Fig.

197 is the smallest size and Fig. 198 the largest size thus far ever used.

OBTURATORS AND PALATES COMBINED.-There is another class of cases, the proper treatment of which has been followed by most encouraging results. For fifty years the operation of staphyloraphy was a favorite one with surgeons, but the cases in which there was only a partial union were largely in the majority. In many instances all that had been accomplished was simply tying together a small portion of the soft palate across the back part of the fissure, leaving an opening, of greater or less size, through the hard palate, anterior to the newly formed septum. This opening has generally been plugged with an obturator, but vocal articulation has been little if at all improved.

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To meet this emergency, a new form of artificial velum was invented. Fig. 199 will illustrate such a case, with the obturator and artificial palate in situ. The patient was a man fifty years of age. The operation of staphyloraphy had been performed twenty years previously, and an obturator of silver, and afterward one of vulcanite, had been worn constantly. Nevertheless, the articulation was not benefited, the reason being the same as in every other case of staphyloric operation; the new fleshy palate, marked A, not being long

enough to close by any muscular effort the passage to the nares. There was, however, some remaining muscular action, to utilize which power was the desired object to be attained. Letter B shows the obturator, and letter C the velum. In this instance the obturator is made of soft rubber, the same as the velum, and when in use the velum is but an extension of the natural palate, as seen in Fig. 199, letter A. Fig. 200 shows the appliance when not in use. The plate D secures the obturator to the teeth, as in other cases of artificial palates. In order to introduce the piece, the broad flap

286

UNDOING A STAPHYLORAPHIC OPERATION.

C should be first passed through the opening in the roof, and pushed back, when the whole fixture will readily fall into correct position. In the case of this patient, the improvement in vocal articulation was immediate and very decided.

Fig. 201 illustrates another case of a similar character, but with incidental circumstances much more interesting. The patient was a lady sixty-two years of age, for whom staphyloraphy was performed in 1845, and the result was a remarkable success, so far as the union of the parts was concerned. The union was perfect throughout the entire length of the fissure, including the uvula; but, although the patient

had applied herself diligently to the improvement of her speech, she was not satisfied with her progress. The fault being too short a palate, the same as in other cases, the remedy must be the same. But here arose another difficulty. There was no opening through the roof of the mouth, as in case of Fig. 199, and there was no method of securing the desired palate extension to the inferior surface of the natural palate. To convey to the artificial velum the action of the levatores palati was essential to success.

After consultation with a skillful and distinguished surgeon of this city (Dr. George A. Peters, New York), it was decided to undo in a measure the operation of twenty-five years before; and an opening was made through the soft