ONE OF THE AUTHOR'S CASES.

357

ARTIFICIAL PALATE AND OBTURATOR.-In 1866 there came to me a lady about twenty-five years of age, with congenital fissure of the palate, which had been operated upon about ten years before by Dr. Hulihen, of Wheeling, Virginia. The fissure of the velum was complicated with an extensive separation of the maxillæ, following the line of

the intermaxillary suture on the right side, dividing the alveolar arch and also the lip. The lip had been operated on in early life. At sixteen years of age staphyloraphy was performed most successfully. The soft palate was united its entire length, including the uvula.

Fig. 238 is copied from a plaster cast taken at the time she came into my hands. In it are shown the fissure of the hard palate and division of the alveolar border, together

358

PLATE OF TEETH, OBTURATOR, AND PALATE.

with the united velum; even the marks of the sutures are distinctly visible in the cast.

For the ten years succeeding the surgical operation the patient had worn an obturator which closed the remaining opening. It was skillfully adjusted, and gave her all the benefit that it was possible to obtain from an obturator alone. But with ten years of application and an intelligence equal to the undertaking, she was unable to articulate with any more distinctness than before the operation. The father said, "If anything, she does not speak as well." There was very little mobility to the palate, and, from the closest calculation, there was a space of half an inch in breadth behind the velum, even when 'the pharyngeal wall was contracted

toward it. Through this space there was a constant escape of the voice. Nearly all the vowels were nasalized; g, k, d, 8, and ch she could not make, owing to such escape.

There was apparently but one solution to the problem, which was to make an artificial extension of the palate to enable it to meet the pharyngeal wall, and thus cut off at times the communication with the nasal cavity. The appliance consisted of an obturator not very unlike the former one, filling the anterior gap, and carrying with it some artificial teeth to supply the loss of some natural ones; and attached to its posterior extremity an extension of elastic rubber, following down the superior surface of the palate to its posterior border and beyond to meet the pharyngeal wall.

MANNER OF INTRODUCING THE APPARATUS.

359

This apparatus is shown in Fig. 239, and in Fig. 240 it is also seen in situ. A shows the obturator, B the elastic extension, and C the apron or palate, occupying the space in the pharynx. The same letters apply to both illustrations.

This instrument was introduced by folding the elastic

extremity together, grasping it with a pair of tweezers, and passing it through the opening in the hard palate, when it would find its natural position on the introduction of the obturator. Subsequently the patient would carry the palate through the opening with the tip of the tongue alone. It created no irritation in the pharynx, and was worn with entire comfort. The only immediate change was in the

360

THE CONDITION THIRTEEN YEARS AFTER.

tone of voice. The vowels and some other sounds were less nasalized.

By my advice she went under the training of Professor Peabody, an elocutionist, and in a few weeks showed very marked change. She acquired the ability to articulate with perfect distinctness every sound of the English language, and in reading, with care on her part, would enunciate every word and syllable without fault.

Thirteen years have now passed, and the few teeth then remaining have succumbed to the influences which destroyed their fellows, and not a natural tooth remains in the mouth. Within the past year the obturator here described has been substituted by another bearing an entire upper set of artificial teeth, and the whole apparatus is worn with as much freedom as its predecessor, which was attached to the natural teeth. The speech has not degenerated, but rather improved in ease.

The interest in this case lies—

1. In the remarkable success attending the surgical operation where the fissure was of such extreme width.

2. In its complete failure to improve the speech or produce any other beneficent result.

3. That a piece of mechanism can be worn in the upper pharynx, and with it a person may acquire distinct articulation.

4. The pharyngeal portion of such an apparatus must be flexible, elastic, and movable.

PART III.

MAXILLARY FRACTURES.

CHAPTER XVI.

LOCATION, DIAGNOSIS, ETC.

FRACTURES of the superior maxilla are not of common occurrence, nor are they so difficult to treat as to involve complicated apparatus, or indeed in many cases any apparatus whatever. The causes, when the bone is in a healthy condition, must always be from some form of violence; while, in an unhealthy condition, so simple a matter as the extraction of a tooth may cause a fracture. Fractures of the superior maxilla rarely occur from violence where the inferior maxilla is not involved. An explosion or blow of such force as to break the upper jaw is likely to break also the lower jaw, which is still more exposed.

An exceptional case is reported by Mr. Charles Tomes, where the ascending loop of a bell-rope caught a man by the upper teeth, and both bones of the upper jaw were torn from their places downward and outward, so that they protruded from the mouth.

These fractures seldom require special treatment. When the displaced portions are replaced, they are not liable to get out of position. There being no motion to the jaw, nor any muscular attachment likely to disturb the fragments, and the bone being quite vascular, union takes place readily. The treatment therefore requires the readjustment of the fragments, the removal of any detached spicule that might cause