stating it as above. The physical and mechanical difficulties to be overcome in the adaptation of this artificial velum are a serious obstacle to the operator, for on the nice adjustment of the instrument to all the parts surrounding the fissure depend entirely the comfort with which the patient wears it, and the consequent use he will make of it. It is essential that it should be accurately adapted to the superior or hidden portion of the cavity, as well as to the inferior or more exposed. To secure this adjustment, impressions of the whole cavity are taken in plaster of Paris. These impressions reveal the conformation of all those parts hidden from the eye, including the floor of the nares, the inferior turbinated bones, the vomer, and the chamber and walls of the pharynx as low down as the fauces. From these impressions plaster models are made in the usual manner, to which models the artificial velum is adapted. The material of which the velum is made is elastic vulcanized rubber, prepared with special reference to this object, and possesses sufficient flexibility to be carried by the muscles in any direction. they may act upon it; also sufficient elasticity to regain, and firmness to keep, its position when the muscles are relaxed. It is so delicate in its structure, that I have never known a single instance of irritation or inflammation of the tissues in contact with it, when properly adapted. The material is moulded into form and vulcanized in metallic moulds, and comes from the mould comparatively finished, ready for use. The metallic mould is preserved, and the number of vela for that particular case can be multiplied indefinitely. It is supported in situ, by resting on the superior surface of the palatine or maxillary bone in the vicinity of the apex of the fissure. It is retained by a very simple attachment of gold connected with it near its apex, and reaching to one or two of the teeth, with sufficient hold around the tooth to prevent its slipping off. But even the presence of natural teeth is not essential to retain it firmly and properly in its position, as in one case which I had under treatment the patient had not a natural tooth in her mouth, and an entire upper and under set of teeth was adapted, and to the upper set of teeth was attached the artificial palate, which was worn with as much satisfaction as in any case that has come under my observation. The difficulty of obtaining a correct impression of those delicate structures in their relaxed and quiet state was a most serious obstacle to success in my earlier efforts, and at that time it was my practice to put the parts under a limited course of training until they would bear handling somewhat without involuntary motion. Since then I am satisfied that this course has been rendered necessary only by my fear of trouble rather than from any uncontrollable irritability of the parts involved. While formerly I allowed several days to elapse before attempting to get an impression, in all my later experience I have taken the impression of the whole cavity and its immediate surrounding structures at one sitting, and rarely is any effort made to swallow until the plaster has hardened sufficiently to resist disarrangement. There are many points of physiological importance developed by this experience which would be most interesting to dwell upon, did not the limits of this paper prevent my presenting them in full. To some of them, however, I must briefly recur. The intellectual capacity of the patient exercises a greater control over the rapidity and amount of progress in improvement than the peculiar physical conformation of the defect. A musical ear cultivated to a nice distinction of sounds is of material benefit in making the most of this appliance. The age should also be taken into consideration, and as early an age as the patient would take an interest in developing its benefits would undoubtedly be preferable. The improper position in which some of the organs of speech are placed in the efforts of the patient to articulate distinctly, becomes so habitual as to be almost impossible to over-· come, and manifestly the earlier the age at which this is attempted before these habits become firmly fixed, the better. I have, however, in one instance adapted an instrument for a patient over thirty years of age, and in another for one over forty, both of whom derived very material benefit from its use within a very few. months. Again, the sensitiveness of the individual to the defect, the mortification experienced, in the exposure by their speech of this deformity, will prove a powerful incentive to their practice and the consequent rapidity of their improvement. It is astonishing with what entire freedom from discomfort or annoyance the velum is worn immediately on its introduction. I have never had a patient where there was any irritation or inflammation in consequence of wearing it, and only in rare cases have they even experienced lameness of the surrounding muscles. The experience of persons wearing the velum is most interesting, especially in the earlier stages. Time will not permit me to give a detailed report of cases. I can only briefly state those points which seem common to them all. Its immediate effect upon articulation is such, as a general rule, that the friends do not understand them as well as before. In fact they seem for a few days to speak better without it than with it. This period gradually passes into the second stage, when they can speak better with it than formerly without it. At this point it is noticeable to those who have watched these developments, that while the individual most certainly articulates far more distinctly with it than they formerly did without it, they also articulate much more distinctly without it than they formerly did without it; so that at this second stage, as I term it, it is almost impossible to show to a stranger any decided contrast of the speech with it and without it. But great encouragement is derived from the fact that, manifestly to all, the articulation is on the whole more distinct than formerly. In a few months, this gradually merges into the third stage, when the patient has acquired far more control of the muscles, and the former misuse of the organs is somewhat overcome; the improvement is most decided when the velum is in position, but when out, the power of articulation seems almost lost. Its effects on deglutition are not remarkable. Ordinarily it produces no annoyance in eating or swallowing; it is tolerated without inconvenience. The patient never having experienced any difficulty of deglutition, cannot of course realize in that direction any improvement. In some cases, however, the first impression is that fluids cannot be swallowed as readily as formerly. This earlier experience soon passes into that when they feel far more comfortable in every respect with it than without it. With reference to the universality of this application, I am of the opinion that but very few cases are brought to the notice of the surgeon for which the operation of staphyloraphy would be preferable. There are some instances on record where there was an entire division of the velum, but the sides of the fissure came nearly or quite in contact when the muscles were relaxed. Such a case would clearly invite a surgical operation. There would be no consequent rigidity of the newly-formed velum, and it would in all probability perform its natural functions. Cases have been brought to my notice where the fissure was slight, sometimes being hardly more than a division of the uvula, and again where the fissure extended but little distance into the velum. These are all exceptions to the general presentation, and a surgical operation for them would probably be preferable. |