CONGENITAL CLEFT PALATE. 
PAPER READ BEFORE THE NEW YORK ACADEMY 
OF MEDICINE, 
NORMAN W. KINGSLEY. 
PROFESSOR OF DENTAL MECHANISM IN THE NEW YORK COLLEGE OF DENTISTRY. 
Reprinted from the Bulletin of the Academjr, January, 1866. 
NEW YORK: 
PRINTED BY THE NEW YORK PRINTING COMPANY, 
40 Ann Street, and 81, 83, & 85 Centre Street. 
1866. CONGENITAL CLEFT PALATE. 
PAPER READ BEFORE THE NEW YORK ACADEMY 
OF MEDICINE, 
By NOBMAN W. KINGSLEY" 
PROFESSOR OF DENTAL MECHANISM IN THE NEW YORK COLLEGE OF DENTISTRY. 
Reprinted from the Bulletin of the Academy, January, 1866. 
NEW YORK: 
PRINTED BY THE NEW YORK PRINTING COMPANY, 
40 Ann Street, and 81, 88, & 85 Centre Street. 
1866. CONGENITAL CLEFT PALATE. 
PAPER READ BEFORE THE NEW YORK ACADEMY OF MEDICINE, 
NORMAN W. KINGSLEY, 
PROFESSOR OF DENTAL MECHANISM IN THE NEW YORK COLLEGE OF DENTISTRY. 
Mr. President, and Gentlemen :—Allow me in advance to 
thank you for the honor you have done me in inviting me to read 
this paper before you. 
More than five years ago I appeared before this honorable 
body, at the invitation of one of the Vice-Presidents, and exhi- 
bited and described an artificial velum, or palate, which I had 
constructed and successfully introduced prior to that time. 
The principles which were adopted in the construction of that 
instrument, and briefly unfolded at that time, have governed me 
in all subsequent operations; and while there has been a radical 
change in the form of the apparatus, the opinions I then held in 
regard to the universality of its application, and the great benefits 
te be derived from it, have, after this lapse of time, only been 
confirmed. 
In presenting the subject of congenital cleft palate, I shall not 
attempt to throw any light upon its origin. It must in the nature 
of things be coeval witb other ills to which the human subject is 
heir. Frequent reference is made by the older authors to its 
existence, but the primal cause of this deformity thus far remains 
unknown and beyond our control; no research has unfolded it; 
all we know is, there is an arrest of development in the earlier 
months of foetal life. 
It does not seem to any extent to be entailed or transmitted to 
offspring. In but few instances which have been brought to my 
knowledge has there been any evidence that the defective organi- 
zation was inherited. In some instances it lias appeared in several 
children of the same parents; but in a large majority of cases 
they are the solitary instances in the family. Neither is there 
any uniformity in its extent. If we take the uvula as the start- 
ing-point, we sometimes find merely a bifurcation oi that organ, 
and from this very slight defect it is presented with every grada- 
tion of extent into the velum, to the posterior edge of the pala 4 
New York Academy of Medicine. 
[Oct. 
tine bones, to the base of the alveolar ridge, and sometimes 
dividing the maxilla along the line of either or both the nasal 
passages. 
The only evils arising from this deformity worthy of our atten- 
tion are its influence on deglutition and articulation. These 
functions being unlike each other, in the fact that the former is 
natural, while the latter is an acquired or a mechanical function, 
it will readily be seen that the loss of any of the organs con- 
cerned may influence the two in a very different manner. A per- 
son suffering from a congenital defect of an organ concerned in a 
natural function, may, by repeated efforts, acquire such control 
over the remaining organs, as to experience no real discomfort 
from their defect. So, with a child born with a defective velum 
or palate, it must, of necessity, find the function of deglutition 
during all the earlier period of its life, and especially while it is 
dependent upon fluids for nourishment, much impaired. To such 
an extent have these poor unfortunates suffered from this defor- 
mity, that there is no doubt many lives have been sacrificed 
solely from want of nourishment. But when the deformity is 
discovered by the nurse, and accommodation made to meet the 
child’s condition, it is very soon able to obtain all the food neces- 
sary to its development, and long before it has attained years of 
discretion it has obtained such control over the remaining organs 
of deglutition as never to experience any great discomfort from 
the defect. I have never conversed with an intelligent patient 
who was troubled with a regurgitation of food, either fluid or 
solid, unless the head was inclined considerably forward. In fact 
the physical comfort of an adult patient with congenital fissure of 
the palate is in no way seriously impaired. 
But in regard to the mechanical function—that of making arti- 
culate sounds—it is quite another thing. The perfection of speech 
being dependent entirely upon the intelligent use of perfect 
organs of speech, it follows, as a necessary consequence, that no 
amount of repeated efforts or practice can make up for the 
absence of organs essential to that acquirement. It follows, 
also, that nothing can produce this result short of restoring to a 
certain degree of perfection the defective organs. We can, 
therefore, come to no other conclusion than that the only demand 
for any method of treatment is with a view of improving the 
speech. 
It is necessary, before proceeding further with this subject, 
that we understand pretty fully the mechanical action of the 
organs concerned in articulation, and particularly the offices of 
the velum; also, for the purposes of this discussion, I desire to 
draw a marked distinction between voice and speech. The terms 
are often confounded, even by learned men, when treating of 
this subject, in a manner which seems to me unjustifiable. 
The term “ voice ” is in common use when speech is undoubt- 
edly meant, and to such an extent, that in reading the works of 1865.] 
'Congenital Cleft Palate. 
5 
authors on this subject, it is sometimes difficult to know whether 
it is simply an improvement of voice they refer to, or whether 
the term is meant to include articulation. By this explanation 
only can I reconcile some apparent impossibilities. 
For the present, therefore, let us consider the term “ voice ’’ as 
applying to all the elementary sounds of language formed in the 
larynx, and speech as applying to the modulations of such 
sounds, by the organs situated between the pharynx and lips 
inclusive. The voice is not affected by a fissured velum. 
It does not seriously interfere with vocalization. With an ear 
for music, a person afflicted with this deformity may be educated 
to the production of all the harmonious sounds of vocal music. 
Singing, then, is not necessarily peculiar, but all those elemen- 
tary sounds of articulate language which are modified to a greater 
or less degree by the velum, are more or less defective, dependent 
to some extent upon the size of the fissure. 
The foregoing remarks apply to the voice as affected by a cleft 
palate, when it is not complicated with hare-lip. 
The influence of hare-lip upon the voice is marked and pecu- 
liar when associated with a fissured velum. I have seen a few 
cases where the deformity was confined entirely to a fissure of 
the lip, extending into one of the nostrils, but they were all adult 
cases, and such admirable operations had been performed in 
childhood upon the lip in each case, that there was not the slight- 
est defect of articulation or peculiarity in the tone of the voice. 
But hare-lip, when associated with cleft palate, may be considered 
as a prolongation of the cleft extending forward, following the 
channel of one or both nates, and terminating in an enlarged 
nostril and a divided lip. The enlarged naris and distended nos- 
tril give a peculiar and unpleasant tone to the voice. I would 
therefore urge upon surgeons in operating for hare-lip, the neces- 
sity of contracting the nostril to as nearly as possible the natural size. 
It is of much more importance to the patient that the size of 
the nostril should be reduced than that there should be a uniform 
border obtained to the lip. 
If there should be a small notch left in the edge of the lip from 
a defective union, the lower lip will be able to meet it and close 
the oval opening ; but if an unnaturally large nostril is left, the 
compressor nasi muscle will not have the power to close it, and 
thus assist in the formation of sounds that belong to articulate 
language. 
It is the modifications of the voice, by the organs before 
alluded to, which come to be understood in the process of time, 
as speech. Articulate language, therefore, to be clear, distinct, 
and uniform, must be the result of the intelligent use of compa- 
ratively perfect organs. The improper use of or the absence of 
perfect organs can only result in defective articulation. 
I am surprised that this matter should have been overlooked 
in many instances by professed elocutionists. New York Academy of Medicine. 
[Oct. 
I have known professors of elocution receive as pupils persons 
suffering from defective organs of speech, with the encourage- 
ment of perfect articulation held out as the result of education. 
It is physically impossible for such a result to follow under such 
circumstances. So far as I have read, it seems to me too little 
credit has been given to the velum, by physiologists, as an organ 
of speech. I would, therefore, claim for it that it exercises a 
more important office in the modulation of sound than any other 
organ except the tongue. By it, in conjunction with the pha- 
rynx, the voice is directed entirely through the oral cavity. By 
it, in conjunction with the tongue, the voice may be directed 
entirely through the nasal cavity; and by it the voice may be 
divided and directed through both channels. On it depend the 
tongue, teeth, lips, and other organs of speech of the oral cavity 
for their current of voice, out of which to make articulate lan- 
guage. It is essential to the purity of any spoken language with 
which the writer is acquainted, that, to produce certain sounds, 
the passage from the pharynx to the posterior nares should, at 
times, be entirely closed, while for other sounds it should be 
entirely open, permitting the whole voice to pass in that direc- 
tion. And in this connexion let me not be understood as con- 
founding the uvula with the velum. So far as my observations 
extend, the uvula exercises no control over the voice ; and so far 
as any injury to articulation might follow, the uvula may be 
entirely removed, providing the velum and the pharynx have 
the power of closing the posterior nares. With congenital fis- 
sure of the palate it is, therefore, physically impossible for a per- 
son to speak the same language as those with perfect organs ; 
and in this way only, in many cases, is this deformity betrayed to 
the society in which the person moves. 
The history of the treatment of cleft palate is comprised in few 
words. Although frequent reference is made in the oldest works 
on surgery to the existence of this defect, in vain do we search 
for any directions for its surgical treatment. The only remedy 
suggested is the obliteration of the aperture by the presence of 
some foreign body, and these appliances, from the descriptions 
given, must have been unscientifically adapted, and could but 
imperfectly have accomplished their object. The earliest record 
of an operation which I have been able to find is that attributed 
to M. Le Mounier, a French dentist, about the year 1760, of 
whom it is said—“ lie attempted with success to re-unite the two 
edgfes of a cleft in the palate of a child, first making several 
points of suture to hold them together, and refreshing them with 
a cutting instrument.” From that date until about the year 
1840 but little or no real advance had been made in the opera- 
tion, and so unreliable was it considered by surgeons that it was 
with but little confidence that they recommended it. 
But from this period a most marked improvement occurred, 
both in the method of performance and the consequent success o 1865.J 
Congenital Cleft Palate. 
7 
the operation. To the scientific attainments of Dr. Mason War* 
ren is probably due as much as to any other surgeon the stronger 
confidence with which staphyloraphy has been regarded to the 
present date; and, although during all the earlier years of its 
history it was accompanied with varying success, it has, never- 
theless, been called in practice so often that, in a surgical sense, 
little else can be desired or hoped for. That this should seem at 
first the most desirable treatment for fissured palate all must 
admit. A patient is presented with a concealed deformity, but 
his speech betrays him. An examination discloses the fact, 
that the membranous curtain which divides the oral from the 
nasal cavity is split from uvula to palatine bone ; but its sides are 
soft and elastic, and it is observed in the px-ocess of deglutition 
that the sides of the cleft approach and come in contact with 
each other. What more natural, then, than the suggestion to 
pare the edges of the cleft and unite them by suture, and thus 
form a perfect septum in place of an impaired one ? 
I will not here go into an analysis of the different methods of 
performing that operation now practised by various surgeons. 
Mr. Fergusson, F.R.C.S., F.R.S., of London, is now universally 
recognised as having had greater experience than any other sur- 
geon who ever lived. I speak from memory when I say that he 
has operated on about two hundred and fifty cases, and claims, 1 
believe, that nearly every one was a success; that is, in a surgical 
sense, he had obtained some union, either partial or complete, in 
all these cases but two or three. 
As a rule, he divides the levatores palati on either side, so as to 
destroy the tension on the sutures. 
Mr. Pollock, F.R.C.S., surgeon to St. George’s Hospital, Lon* 
don, has probably performed the operation as often as any other 
man, with the exception of Mr. Fergusson. 
I had the pleasure of frequent conversations with him upon 
this topic within the past year, and although possessing consummate 
skill, arid ranking as high as any surgeon in Great Britain, he 
does not claim for himself such unvarying success as does Mr. 
Fergusson. His method varies somewhat from Fergusson’s, but 
he nevertheless divides the same muscle and arrives virtually at 
the same result. 
Other operators of London are more or less imitators of the 
foregoing. I was introduced by Professor Syme of Edinburgh to 
a pupil of his, Professor Annandale, also of Edinburgh, a young 
man of fine promise, who has recently met with much success in 
his operations for this- deformity on a different and what I con* 
ceive to be, when practicable, a far better method. His opera* 
tion consists in making an incision in the mucous membrane 
parallel with the lingual surfaces of the teeth, and dissecting oft 
the tissue, finds it sufficiently relaxed to bring the edges of the 
fissure together, wdien they are united in the usual way. He 
claims his ability by this method to not only obtain a union with- 8 
Neto York Academy of Medicine. 
[Oct. 
out the destruction of any muscle, but to obtain also a deposition 
of bone by the bridging over of the fissure in the hard palate 
with the periosteum dissected off and drawn from the sides. He 
has to all appeai*ance accomplished this in more than one instance. 
In Paris, while the operation of staphyloraphy was first accom- 
plished by a Frenchman, and while the hospitals of Paris boast of 
some of the most skilful surgeons living, this operation has been 
almost if not entirely abandoned. 
In our own country, so far as I can learn, there has been no 
such extensive experience as that recorded of the hospitals of 
London. 
To Warren of Boston, and Mutter of Philadelphia, has been 
accorded I believe the most experience of any in the country. 
But either the deformity is more rare, the cases more scattered, 
or the aid of the surgeon is not called in, and thus no one man has 
acquired such extensive practice in this line as have some abroad. 
But thanks to all these men and many others, they have by their 
consummate skill carried this operation to such a state of perfection 
that they have proved all that can ever be claimed for it. What- 
ever may be the future of staphyloraphy, their operations will 
form a brilliant page in the history of surgery. 
I have dwelt at some length in the beginning of this paper on 
the only object of any treatment of congenital cleft palate, being 
with a view of improving articulation. How will staphyloraphy 
stand the test ? Has it, as a rule, enabled the patient to conceal 
the evidence of the deformity from society ? Or, in other words, 
has it proved in any number of cases that it can be relied upon to 
enable a patient to articulate so clearly and distinctly as not to 
continually betray the defect ? That it does improve articulation 
in many cases somewhat, and perhaps all more or less, all candid 
minds must admit, from the abundant statements to that effect. 
But if there is no serious difficulty experienced from a fissured 
palate in deglutition, and the only discomfort worthy of notice is 
the mortification arising from unintelligible or defective articula- 
tion, how far does limited improvement in speech answer the end 
desired and hoped for, and how far does it justify a tedious and 
painful operation, so long as the deformity is still patent to all ? 
In this connexion let me quote from the highest living authority.* 
“The grand practical object of this operation is to improve the 
voice and articulation. Defective deglutition from this malforma- 
tion is what attracts the mother’s or nurse’s attention in early life. 
The cries of infancy are in nowise peculiar in tone; but when defi- 
nite articulation commences, or rather should commence, the 
value of an entire palate is then appreciated. The air and sound, 
in passing outwards through the larynx, escape in part through the 
nostrils by the split in the palate. A nasal twang is the result, 
and articulation as in the normal state is impossible. Immediately 
_* Mr. Fergusson, F.R.C.S., F.R.S., June, 1864. 1865.] 
Congenital Cleft Palate. 
after the operation the modification on the voice can be at once 
detected. . . . Improved articulation, however, comes slowly. 
Years, many years, are required for distinct articulation; and after 
the most successful operation for cleft palate months and years 
are required to alter defective sounds. Voice and speech have to 
be modified anew. With some the changes come slowly and 
sluggishly; but with others they are so rapid and perfect that 
within a few years the original defect cannot be detected except 
by a practised ear.” Out of the large number of surgical suc- 
cesses, is it a rule that the patient is recompensed for the suffering 
undergoue by the result obtained ? I must confess I have no 
statistics to offer you in answer to these inquiries. While I have 
seen many cases where there was a good union throughout the 
entire length of the former fissure, I have never seen one where 
the speech was not more or less defective, nor where the friends 
considered that it was very materially improved. And the 
opinions now entertained iu France may be said to perfectly coin- 
cide with those I have here advanced. 
In the London “ Lancet” of Nov. 19, 1864, I find a review of 
an article furnished by Mr. Pollock on “ Staphyloraphy ” for the 
fourth volume of “ Holme’s System of Surgery,” from which I 
make the following extract:—“ It is, we believe, a fact that the 
success which French surgeons have met with in this operation 
is so indifferent that it is practically abandoned in the French 
hospitals, notwithstanding the early trials by which Roux connect- 
ed his illustrious reputation with staphyloraphy. The French 
surgeons now entertain the idea that, on the whole, the defect is 
best left to mechanicians Rut it is a very doubtful ques- 
tion whether surgery is exalted by thus surrendering its triumphs, 
and calling in the aid of a mechanist to supply defects which may 
be remedied by their surgical obliteration. Surgeons undertaking 
staphyloraphy should, however, always bear in mind one circum- 
stance connected with the results of the operation. The most 
complete success in restoring the palate by union of the cleft by 
no means implies restoration of the articulation to a natural or 
intelligible standard. Long after, or even for ever after, the suc- 
cess of the operation, in a surgical sense, the patient may continue 
to speak in a manner hardly less unintelligible and disagreeable 
than before. The use of the new palate can only be acquired by 
careful and intelligent practice in the mechanism of articulation. 
Much perseverance and careful tuition are constantly necessary 
to attain this end.” lean readily conceive, however, of rare 
presentations, where, with abundance of material, a long uvula 
and a good union, without much injury to the muscles, clear and 
distinct articulation ought to follow* Indeed, I have it upon the 
very excellent authority of my friend Dr. Mussey, of Cincinnati, 
that a patient of about twelve years of age for whom he operated 
a few years since, is now enabled by the result of that operation 
to articulate perfectly. But in a large majority of cases, I think 10 
Meie Yorh Academy of Medicine. 
[Oct, 
I am justified in saying that such a result is impossible. My 
reasons for so sweeping an assertion are as follows-The newly 
formed septum is too short at the boundary of the fauces, and 
generally somewhat more depressed than it would have been if it 
had united during its formation, thus contracting the passage 
between the tongue and the velum; the power of the levator 
muscle has been much weakened by the knife ; the newly formed 
septum is either taut or paralysed, and from this combination of 
causes the passage through the nares remains permanently open, 
thus permitting a large volume of voice to escape without the 
power of the tongue to exercise any control over or modify it. 
The ability to articulate any spoken language correctly must 
remain an impossibility so long as the velum and pharynx are 
unable to meet, and at will shut off that pasaage. I apprehend 
that on this point alone rest all the failures of whatever treatment, 
for the difficulties to be overcome at any other point are compa- 
ratively slight. If staphyloraphy, then, comes so far short of 
accomplishing in a majority of cases all that is desired, we are very 
naturally led to inquire, is there any hope from any other source ? 
Obturators have for a long time been resorted to for this 
object; and when we consider that probably the earlier appli- 
cations of this instrument were for perforations of the palate 
induced by accident or disease, and that their good offices were 
made apparent immediately, it is not to be wondered at that 
much was expected from their use in congenital cases, and 
especially so when the true principle upon which an instrument 
should be adajjted was so little understood. It is hard to recon* 
Fig.i 
Fig. 1 represents a model of a fissured palate, complicated with hare-lip oil the left of the 
mesial line. There is a division also of the maxilla and the alveolar process : the sides being 
covered with mucous membrane which come in contact with each other, but are not united. 
The left lateral incisor and left canine tooth are not developed. 1865.] 
Congenital Cleft Palate. 
11 
Fig.% 
Fig. 2 represents the artificial Velum, as viewed from its superior surface, together with 
its attachment and two artificial teeth to fill the vacancy. 
The lettered portion of this appl ance is made of elastic vulcanized rubber; its attachment 
to the teeth of hard vulcanized rubber, to which the velum is connected by a stout gold pin, 
firmly i ubedded at one end in the hard rubber plate. The other end has a head, marked C, 
which being considerably larger than the pin, and also 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 naris), and 
effectually prevents all inclination to droop. 
't he wings, AA, reach across the pharynx, at the base of the chamber of the pharynx, 
behind the remnant of the natural velum. 
The wings, DD, rest upon the opposite or anterior surfaoe of the soft palate. 
Fig. 3 
Fig. 3 represents a model the same as Fig. 1, with the-suppliaaoe Fig. -2, in situ. 
The wings, L>D, in Fig. 2, and the posterior end «f the artificial velum only, in this cu 
being visible. 
■eile the statements which have passed into history of the perfect 
results obtained by their use in congenital fissure. An obturator 
properly adapted as a bridge to span a simple perforation of the 
hard palate, from whatever cause induced, will accomplish all that 
any treatment can; but there its mission virtually ends. To 
claim that, with a fissured velum, the gap can be bridged over 
or the posterior nares plugged and perfect articulation will follow, 
is to claim an absurdity—a total impossibility. A great deal of 12 
New York Academy of Medicine. 
LOct. 
ingenuity has been wasted in their construction, and the claims 
for them must have been made in advance, without waiting for 
the proof. In the present state of science and art our only 
remaining hope of relief is the substitution of an elastic artificial 
appliance to fill up the gap. This simple idea is not a new one, 
neither is the application of it of recent date. Elastic artificial 
vela have been made, or attempted to be made, of some form or 
other, almost ever since the use of india-rubber for mechanical 
purposes, and I do not know but of other materials long before, 
One thing, however, is certain—the application of suitable elastic 
material in skillful hands for the treatment of these cases is capable 
of producing far more satisfactory results than have heretofore been 
derived from any other source. The indications to be fulfilled by 
such an appliance are—an obturator, or covering for the cleft, 
which shall be perfectly adapted to the muscles against which it is 
to lie ; shall be flexible, susceptible of all the motions of the velum 
or soft palate itself; shall be durable; easily detached and replaced 
by the patient; and, in a word, shall be so under the control ot 
surrounding muscles, when in situ, that the patient has the power, 
which in a normal state he would possess, of directing the voice 
at will either through the mouth or the nasal cavity, or both, as 
desired. 
Such an instrument as that described has been brought to 
such a state of perfection that I have no hesitation in saying that 
it can be adapted to any case of congenital fissure of the velum 
that is usually seen, whether complicated with a fissure of the 
maxilla or not. It can be made so as to be retained in situ, 
without danger of misplacement; can be worn all the time from 
the first hour without discomfort; is capable of being raised and 
depressed, also to allow the sides of the fissure to contract (as in 
the process of deglutition) without interference, and is so simple 
that a child cannot disarrange it to its detriment. Such an appli- 
ance renders it perfectly possible for the patient to learn to speak 
well. 
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 depends entirely the comfort with 
which the patient wears it, and the consequent use he will make 
of it. 
The movements produced by the superior constrictor muscle 
of the pharynx upon the remnant of the velum in the act of 
deglutition will be remembered. In the proper adaptation of an 
appliance arrangement should be made for this movement. If 
not provided for, the act of deglutition would compel it to fold 
upon itself, and thus interfere with that function; or, if too 
unyielding, it would irritate the surrounding tissues, until it could 
not be borne. 
It is so delicate in its structure that I have never known a 18d5.] 
Congenital Cleft Palate. 
13 
single instance of irritation or inflammation of the tissue in contact 
with it when properly adapted. 
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 fis- 
sure. 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 suflicient 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 artificial teeth was adapted, 
and to the upper set of teeth was attached the artificial palate, 
which was worn with as much satisfaction as any case that has 
come under my observation. 
There are many points of physiological importance developed 
by this experience, which would be most interesting to dwell 
upon did not limited time prevent my presenting them in full. 
To some of them, however, I must briefly recur. 
The intellectual capacity of the patient exercises a greater con- 
trol over the rapidity and amount of improvement than the pecu- 
liar 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 con- 
sideration, and as early an age as the patient would take an inte- 
rest in developing its benefit 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 overcome, 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 years of age, both 
of whom derived very marked benefit from its use within a very 
few months. 
The earliest age to which I have adapted these appliances is 
eight years, and of all ages varying between these extremes. 
Again, the sensitiveness of individuals to the defect, the mor- 
tification 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 had but two patients in whom there was any irritation 
or inflammation in consequence of wearing it; and in those two it 
passed away entirely within a day or two, and only in rare cases 
have they ever experienced even a lameness of the surrounding 
muscles. 
It will naturally be asked, what has been the result of this 
treatment in any number of cases. I can state most confidently, 14 
New York Academy of Medicine. 
[Oct. 
a decided improvement in speech within a very few weeks, a 
clearness and distinctness of utterance which the patient never 
showed before. In some cases this progress has been so rapid 
that, within a period of six months after its first introduction, the 
wearer would not from his speech be suspected by the ordinary 
observer of possessing such a deformity ; and in every case, within 
a few months the speech has improved so much as to render it 
perfectly intelligible to strangers without repetition. It must not 
be supposed from these statements that there is any marked 
change in articulation immediately. There is almost always an 
immediate change in the tone of the voice, which is much less 
disagreeable than formerly, and this change is often mistaken for 
an improvement in articulation. 
I desire to be distinctly understood, that the remarks in this 
paper apply to cases of congenital cleft only. I have referred 
only incidentally to fissured palate, from any other cause induced. 
I am thus careful to make this distinction because the application 
of an instrument to any other than congenital cases is so compa- 
ratively simple, and the results so quick to manifest themselves, 
that it forms no criterion by which to judge of the treatment of 
congenital fissure. A person who has once possessed the power 
of distinct articulation, may lose to a certain extent some of the 
organs concerned in that function, and the remaining organs may 
be so developed as to completely hide the loss. The educated 
ear then seems to exercise such a power over the defective organs 
as to develop an extraordinary usefulness. These malformations 
are manifested much more in the attempt to articulate some lan- 
guages than others. 
There is a most interesting field of inquiry for the physiologist 
growing out of this subject, to which I have neither the time nor 
the ability to do justice. I can only glance at it. 
In the articulation of the Anglo-Saxon tongue the compressor 
nasi muscle is very seldom, if ever, called into requisition. In 
the cases of deformity which we have been considering the 
escape of voice through the nostrils is so great that the individual 
vex*y soon forms the habit of using that muscle constantly. The 
result is he acquires the power of making such sounds as do not 
belong to our language, but which nevertheless do form a very 
prominent part of other cultivated tongues. That muscle is much 
more frequently used in speaking the French language than our 
own. It will be readily understood, then, that these persons 
(other things being equal) can much sooner learn to speak the 
French language correctly than our own. With that language 
that habit assists them, with our own it must be broken up. It 
must also be borne in mind that it is much more difficult to break 
up the habit, when fully formed, of speaking a language badly 
than to acquire the power of speaking a new one correctly. The 
Irishman can much sooner master a foreign language than he can 
correct the brogue with which he speaks his native tongue. I860.] 
Congenital Cleft Palate. 
15 
In some of the cases which we have had under consideration it 
has already been proved that they learn to master a foreign lan- 
guage even more readily than their own. 
In all cases where patients have been under treatment either 
by surgical or mechanical means, I would urgently recommend a 
course of practice which would tend to develop the latent 
powers. A course of lessons in articulation from a competent 
instructor, or the study of a foreign language, would be admira- 
bly adapted to that end. 
In conclusion, I desire to add a brief extract from some 
remarks made by Mr. Pollock before the Odontological Society 
of London on this subject during the past year :— 
“ Mr. Pollock—As one who has taken some little interest in 
the question of congenital cleft palate, I consider it my duty to 
rise to pay my tribute of respect and admiration to Dr. Kingsley 
for the very eminently practical and ingenious apparatus which 
he has brought before us this evening. I look upon it as one of a 
series of those very great improvements that have come from the 
other side of the Atlantic, which have conferred so much benefit 
on mankind. I cannot but feel, from the experience I have had 
ip the treatment of congenital cleft palate, that the operation for 
closing it by surgical means is not always a satisfactory operation. 
There are a few cases which certainly offer every facility and 
every advantage for the operation, and in those few cases we do 
succeed, in time, in procuring a considerable amelioration, if not 
almost perfection in articulation. I have in many cases observed 
a considerable improvement, I might almost say, an immediate 
improvement in the voice, and a subsequent and slow, but a very 
uncertain, improvement in the articulation. There is very often 
a large aperture between the mouth and the nares, which pro- 
duces a most disagreeable cavernous resonant sound in the voice. 
That has been very much modified by operation in more than one 
instance, without, I may say, much material improvement in the 
articulation. So much with regard to the operation ; but I am 
sure everybody in this room who has witnessed any number of 
congenital clefts will feel with me, that there is a class of cases 
in which a surgeon would not only be rash, but he would be very 
much to blame if he undertook an operation. I allude to those 
cases in which the soft palate is what you may call thin and defi- 
cient in quantity, in which the uvula is but a small point project- 
ing on either side from a little curtain, which is drawn up on each 
side of the fauces. I have myself refused to operate in more 
than one such instance.”