Rotter records a third instance.[96] It was in a case of very wide right-sided harelip with cleft palate, in which Langenbeck’s operation had been successfully performed in so far as union in the middle line was concerned but the left palatine process was so nearly vertical that a lateral cleft half an inch in breadth resulted. This was repaired by a modification of Blasius’ operation. A long cutaneo-periosteal flap was taken from the forehead; the raw under-surface was grafted and allowed to heal entirely before being placed _in situ_. To accomplish this it was merely necessary to draw it through the still unclosed harelip to pare the edges of the flap and of the cleft, and to fix with sutures the former within the latter. When united firmly, the pedicle was divided, and the harelip closed. A good result followed, and was maintained two years later. Such procedures can only be necessary in exceptional cases. Permanent scarring of the face is always to be regretted, and Langenbeck’s method or some slight modification of it, carefully and skillfully carried out, should meet nearly all contingencies. There is an instance recorded by Wolff[97] where the whole of the right-sided flap in a case of uranoplasty became gangrenous, leaving a wide opening which, however, was successfully closed subsequently by a repetition of the same process. CHAPTER VII. ON OBTURATORS AND ARTIFICIAL VELA. Before the year 1830, when operative treatment for the closure of cleft palate first attracted attention, and began to be recognised as a legitimate surgical procedure, the only means of alleviating the troublesome symptoms resulting therefrom was by the use of artificial mechanical appliances; and in spite of the increased safety and certainty, the outcome of increased knowledge, with which such operations are now performed, the use of these has not been entirely superseded, and in America they are still much in vogue. These appliances are called obturators or artificial vela according to their position and function in the mouth. “An _obturator_ is a stopper, plug, or cover, stationary, and fitting to an opening, with a well-defined border or outline, and closing the passage. “An _artificial velum_ is an elastic moveable valve, under the control of surrounding or adjacent muscles, closing or opening the posterior nares at will, and applicable to cases of congenital cleft, occasionally when the soft palate has been destroyed by ulceration, but never merely to perforations of the hard, or soft palate.”[98] Such are the Utopian definitions given by American dentists. It may be interesting to pass in review some of the ingenious appliances which have been from time to time suggested, and to indicate some of the various steps in the progress of their production.