may be attained, lies in early operation. The evidence advanced by Dr. Fillebrown is entirely negative, for the fact that certain operations in individual cases have resulted in perfection of speech does not in any sense inveigh against the principle that the earlier the operation the better. I have seen persons with large clefts in their mouths who might mingle freely with this audience and not be detected by their speech. The few successes which Dr. Fillebrown has had that is, few in proportion to the many thousands of operations that have been performed upon adults do not weigh at all in the balance of the argument that surgical operations performed upon adults prior to those of Dr. Brophy have been a failure and a blot upon surgery. What success Dr. Brophy has had with his operations on adults, or on children old enough to have acquired bad habits of speech, seems to me very largely dependent upon his technique and upon a point which in the past has been overlooked by surgeons, and which at present, with the exception of one or two men, has been ignored by dentists when attempting to restore speech by artificial means. Surgeons and dentists have taken the cases as they have found them, and have attempted to simply occlude the sides of the cleft-in the case of surgery by plastic operation, and to plug them up in the case of dentistry. Sometimes the result was a high vault which the tongue never reached in articulating those sounds where it was essential that it should touch the roof of the mouth. Dr. Brophy's operation peels the soft parts away from the palate bone and brings them down so that an entirely different vault, less in height, is produced, thus enabling the tongue to reach those parts, and thus producing satisfactory speech. The same is true of the Kingsley obturator. This is not simply a plug in the back of the throat, but in all cases the mouth is studied and the plate is made not to form too high a vault, but to bridge it and produce a lowering of the dome, thus allowing the tongue to reach the roof of the mouth in the formation of those sounds. It would surprise me very much to find that the phonographic records of Dr. Fillebrown are of any value. While the articulation may be very often obtained by surgical or mechanical means, one of the most difficult things to overcome is the nasal resonance, and I have never heard a phonographic record, even from a normal voice, that did not conspicuously show what seemed like nasal sounds. Conse

quently those records would not indicate at all whether or not the patient had overcome his nasal resonance, and would give an entirely inadequate report of what he could do. It seems to me that some of the plastic operations might be much improved, and especially that if the nares could be properly occluded anteriorly and posteriorly the nasal resonance would be overcome. In making an obturator it would be of advantage, before making the final instrument, to test it in the mouth for days at a time, building up or cutting down as needed, to see whether the nasal resonance could be

overcome.

Dr. Brophy, closing discussion: I brought out these pictures to show beyond the question of doubt that the operation which I have devised cannot close the nasal passages. I have never referred directly to the utterances against this operation, based on the supposition that it would cause nasal stenosis and produce greater deformity than that which previously existed. This statement was also made in a textbook written by Dr. Marshall, and it was not based upon any positive information but upon a theory. I recently made sections of an infantile cadaver to show the normal relation of the walls of the nares, the relation of the upper to the lower jaw, the expansion of the nasal passage in deformed patients, and to establish the fact that the upper jaw is widely spread. As Dr. Roe has stated, we have not only a cleft throughout the length of the palate, but having that cleft the separated maxillary bones grow wider apart by reason of the force exerted upon those inclined planes within the alveolar borders by the pressure of the lower jaw, and I contend that this occurs in embryo. I am entirely satisfied that this spreading occurs before the child is born and continues up to the time when the process of ossification is extended so that the bone will no longer readily yield to the pressure of the lower jaw upon the inclined planes formed by the arch of the upper jaw.

I have long been on record as urging early operations, though I recognize the value of later operations, because we sometimes restore perfect articulation in them, but in other cases this is impossible.

Dr. Kingsley reports the case of a man for whom he adjusted with the greatest of care an obturator, and who in the hands of an elocutionist learned to use the instrument so that he could speak very well. Later he developed a nasal tone and lost to a considerable ex

tent the results of the training, simply because he grew careless. No matter what sort of a palate is made for a patient, no matter how perfect it may be, and no matter how successful technically the operation may be performed, he will continue to speak badly unless he is carefully trained. Dr. Kingsley has clearly and beautifully outlined the behavior of the tongue in the enunciation of sounds, and has shown its position in pronouncing certain ones. Take for example the consonants, t, k and s. To pronounce the letter t the tongue must be placed against the upper incisors or back of them, and then quickly retracted as the expulsion is made to produce the sound. These consonants always bother a cleft-palate patient, and in trying to pronounce the letter t the tongue will lie flat on the floor of the mouth, and he will make a terrific expulsion of air, but to no purpose. All of the technique and mechanical manipulation of the tongue must be taught a cleft-palate patient who speaks badly.

SECTION I.

Prosthetic Dentistry, Crown and Bridgework, Metallurgy, Chemistry and Orthodontia.

Premature Extraction of Deciduous Teeth.

PAPER BY H. A. PULLEN, OF THE SECTION.

One of the chief causes of complication in the diagnosis and treatment of malocclusion of the teeth, coupled with injudicious extraction of permanent teeth, is the premature loss of deciduous teeth by extraction or decay. The deciduous teeth are often wantonly sacrificed by the dentist, who, although he may be relieving suffering, seldom stops to consider the effect upon the harmonious development of the permanent teeth, trusting to Nature to bring about normal arches, no matter how badly she is abused. Again, caries is responsible for the premature loss of the deciduous teeth several years before the time for their successors to appear. Also, these teeth are extracted by parents for their children without advice from the dentist.

The exact time for the natural loss of such teeth cannot be stated definitely, but varies with the individual, the tooth in question, and the prompt or retarded development of the succeeding permanent tooth. The ideal time is, of course, just when the permanent successor has reached the level of the alveolus, preparatory to eruption through the gum tissue, the roots of the corresponding deciduous tooth having been absorbed, permitting its easy removal.

Now, as to the effect of such loss upon the development of the permanent teeth in their correct position in the arches. If the deciduous tooth is extracted eighteen months or more before the time for the natural eruption of the successor, partial or complete closure

of the space almost inevitably takes place, thus shortening the arch by the width of that tooth, and producing a lack of harmony in the relation of both jaws that is very apt to cause a serious irregularity unless operated upon in time. Interstitial growth of the jaw is interfered with at the same time, accounting for the lack of development in the region of the lost deciduous tooth.

Common observation reveals the fact that the deciduous teeth are very seldom irregular. We usually find harmony in size and shape of arches, jaws and teeth during the period of retention of the deciduous set as a whole. It is only when one or more of the deciduous teeth has been prematurely extracted that irregularities begin to

manifest themselves, and these usually appear as shortened lateral halves, undeveloped arches, and consequent lack of room for the erupting permanent teeth. The photographs of models illustrate cases in which deciduous teeth have been extracted, causing either primarily or secondarily some irregularity of the teeth.

On the first model, illustrated buccally and occlusally in Figs. 1 and 2, the cause of the irregularity is primarily from the loss of the inferior second deciduous molar on the left side. It will be noticed in Fig. I that the case belongs to Class I (Angle), the jaws being in normal relation from the first molars distally, the irregularity being confined to the teeth anterior to the first molars, and consisting in a contracted lower arch, principally on the left side where the space of the lost deciduous molar has been closed up. (See Fig. 2.) The lower incisors are considerably distal to their normal positions. As