Not infrequently a fold of membrane is seen running obliquely downwards and backwards across the tonsillar space, usually immediately below the inferior border of the tonsil. When, associated with this condition, the tonsil is swollen, it appears as though bound down in part by this band. The fold is more often At times it is continu

seen in cases where the tonsil is atrophied. ous with the palato-epiglottic fold, or terminates in the lower portion of the palato-pharyngeal fold. See diagrammatic representation, Fig. 4.

A. The tonsil.

B. The lower portion of tonsillar space exposed by representing the tongue as depressed. C. The adventitious fold described in the text extending obliquely downwards and inwards to join either of the two folds as indicated.

D. The posterior wall of the pharynx with lentil shaped swellings about the orifices of tubular glands.

(b.) The Uvula.-This body is so conspicuous a feature of the soft palate, that little of novelty remains to be said of it. It may be briefly mentioned that the uvula is very frequently twisted, or inclined to one or the other side; that it may become indurated from long-standing infiltration, and instead of contracting at the last stage of the act of deglutition is tilted forward into the mouth; that the frequency of ulcerations at the side of the uvula at or near the base is due to the contact of the tonsils, which have become so enlarged as to press upon and if bearing ulcers at the time, to inoculate the uvula at the point of contact; that, probably from a similar cause, the grayish deposit of a recent angina will be transmitted from the palate to the uvula after the manner described.

In the course of the examinations upon which this communication rests, three examples of congenital cleft of the uvula were met with, two of which were complete. I have seen one case where from ulceration the right lateral border had long since been destroyed, and the uvula carried permanently over to the left side of

the median line, where it remained lodged at about the apex of the corresponding tonsillar space.

(c.) Præ-Coronoid Space.-The soft palate has, by its union with the tongue through the palato-glossal fold, an important relation to the lower jaw. (Figs. 1 and 5.) This relation is not of the same value in all individuals; and in some it does not exist at all. Persons with deep mouths, such as negroes, have it less pronounced than those with shallow mouths. Jaws with prominent angles yield the peculiarity less decidedly than where the angles are receding. In an average case, the mucous membrane covering the anterior aspect of the soft palate, while it extends to the tongue along the palato-glossal fold, merges at the same time into the gum tissue of the lower jaw and the floor of the mouth.

Fig. 5. Diagrammatic view of the soft palate, tongue, and portion of the dental arch designed to illustrate the relation of the soft palate to the floor of the mouth; also to show the position of the præ-coronoid space.

A, A. The upper letter indicates the basal portion of the soft palate anteriorly; the lower one the floor of the mouth.

The latter portion, as already noticed, is distinguished by its whitish color, and has commonly upon its surface a vein whose thickest portion is downward as though it emptied into the lingual veins. The former extends over the pterygo-maxillary ligament downward and forward to the gum tissue about the last molar tooth of the lower jaw. This mucous membrane between the two dental arches may be called the præ-coronoid space, and is remarkable for the changes occurring in its relations during the acts of elevation and depression of the lower jaw. When the jaw is elevated the space is much shortened; it is flexed acutely upon

itself; the portion terminating about the wisdom tooth is brought up to the level with the body of the soft palate; and the posterior end of the ridge upon the mucous membrane of the cheek tends to plug up the space from without. As the jaw is depressed, the fold disappears. This mobility is associated with a layer of loose connective tissue between the mucous membrane and the basal portion of the coronoid process which it covers. The relation between the mucous layer and the bone is somewhat analogous to that seen between the pharynx and the vertebral

column.

The præ-coronoid space has certain clinical bearings of interest. Observant dentists have long been aware that an incautious application of arsenical paste to an exposed pulp of the terminal lower molar is productive oftentimes of an early and general diffused inflammation of the soft palate. This has been known to extend from the buccal around to the lingual aspect of the tooth by its cingulum of gum, thence, when the jaw is closed, to find easy access by general relaxation of the part directly to the soft palate. An experienced operator has informed me that while engaged, on one occasion, in preparing the lower wisdom tooth prior to filling, his instrument slipped and caused a slight punctured wound of the mucous membrane of the præ-coronoid space. This apparently insignificant lesion caused in the course of a few hours a general tonsillitis and staphyllitis, which terminated in suppuration. Before the abscess opened, which it did spontaneously, dyspnoea with profound prostration were announced.

On the other hand this space may be involved directly from the palate. (See Fig. 9.) The point where the buccal ridge of mucous membrane adjoins the space is not infrequently the site of mucous patches.

When submucous infiltration of this region occurs, may not its influence upon the internal pterygoid muscle furnish a more satisfactory solution of the origin of direct trismus than we have hitherto had?

Luschka (Schlundkopf des Menschen 1868, Tab. 2) defines this space without describing it. The only allusion I have seen made to it is in Kohn.' He briefly indicates it as follows:

Die Syphilis der Schleimhaut, der Mund, Rachen, Nasen und Kehlkopfhöhle, 1866, p. 380. I am indebted to Dr. R. M. Bertolet for my knowledge of this memoir.

"A broad band of mucous membrane extends across the space between the wisdom tooth and the anterior edge of the coronoid process. It represents a union between the muco-periosteum (gum), and the membrane of the general oral cavity."

(d) The Palato-pharyngeal Fold.-This is a more powerful band than the palato-glossal. It is a conspicuous ledge of mucous membrane, extending from the soft palate downwards toward the lateral wall of the pharynx. It arises from the former at about the basal third of the side of the uvula. The two folds can form a true arch only when at rest. It then receives the uvula toward its summit. The sides of the arch approximate more nearly than do those of the palato-glossal folds.

The palato-pharyngeal muscle, the basis of the above fold, is inserted by a fan-like dispersion of its fibres within three different regions; one passes across the median line to decussate with those of the opposite side, others continue downward to be inserted into the thyroid cartilage.

In chronic pharyngitis, more particularly the syphilitic variety, I have been struck with the frequency with which ulceration and cicatrization are seen within the pharynx, about the place of insertion of the above folds. In those not rare conditions of masses of tenacious mucus plugging, the orifice of the Rosenmüllerian fossa, I have sought an explanation for the co-associated irritability of the pharynx, by recalling the fact that every act of deglutition necessarily brought the palate in contact with this plug or on a line favorable to the descent of the mucus therefrom.

The palato-pharyngeal folds, as a rule, are symmetrical, and run very obliquely downwards and backwards. The observer will often find the degree of this obliquity varying, thus determining corresponding varieties in the proportions of the tonsillar spaces and the naso-pharyngeal aperture. The latter may be so much narrowed as to interfere with, if it do not entirely prevent a post-rhinal examination. These departures from the average description of this portion of the pharynx are more frequent than is generally supposed. Submucous infiltration and atonic relaxation are the fertile causes of such deformations, apart from the more rare ones of cicatrization.

Another fact it is necessary to remember before proceeding fur

See Von Tröltsch, trans. by Dr. St. John Roosa, 1869, p. 304.

ther. It is this: The mucus descending from the nose is prevented from appearing at the upper margin of the oro-pharyngeal aperture by the convex swelling at the upper margin of the base of the uvula, but is guided downward by the palato-pharyngeal ledges to the posterior pharyngeal wall. Should the mucus be tenacious, the moment it reaches the wall of the pharynx a contraction ensues, and the irritating particle is ejected.

These folds are to the naso-pharyngeal space both the boundaries to its gate and its sentinel. As they are sensitive to secretions, so they resist interference with instruments. The passage of the Eustachian catheter by the nose is a signal for the untrained palate to ascend, and the folds to approximate. The merest tyro in rhinoscopy knows how necessary it becomes for him to avoid touching these folds with the mirror. The best trained throat resists interference with them. The space between the folds is thus seen to be often excited by the constant irritation of its parts. Submucous infiltrations may arise from this cause, and be capable of assuming great importance in the study of pharyngeal disease. It is more especially immediately to the inner side of the palatopharyngeal fold that such infiltrations, as well as ulcerations, are seen. The folds when thus complicated have been mistaken for engorged tonsils, which they may in extreme forms in a general way resemble. The space between these adventitious folds is liable to ulcerations. In a case observed at the Philadelphia Hospital, the inferior margin of this ulceration corresponded to a transverse line drawn midway between the two folds, extending thence a distance of four lines. In some cases they are much more extensive. The following note is descriptive of an example of this kind.

T. P. contracted chancre in the summer of 1868. Indurated glands soon thereafter were announced in the groin. These never suppurated. Six months after the chancre appeared, the throat began to annoy him, compelling him to seek admission into the hospital in the winter of 1869. He was discharged May, 1870, much improved; readmitted September 30. The parts about the oro-pharynx, at the time when the note was written, were in the following condition. Uvula and left palato-pharyngeal fold were destroyed by ulceration. The right palato-pharyngeal fold was lost, excepting its lower third. The tonsil of the left side was destroyed in great part. The entire posterior wall of the pharynx