Again these appliances cannot be fitted to a patient much before the age of fifteen, and the habit of defective articulation has been fully formed by that time. They also need constant renewal, and are thus a source of continual expense, putting them beyond the reach of hospital patients. In spite, therefore, of the optimistic arguments so boldly maintained by our American dental confrères, and of the successes they claim to have attained by the use of these artificial means, I am driven to the conclusion that in the majority of cases of cleft palate operative interference, followed by a suitable educational course, will give results incomparably superior to these, and unattended by the above-mentioned disadvantages. But whilst strongly maintaining the superiority of the treatment by operative rather than by mechanical means, I will readily grant the greater applicability of the latter in certain conditions; viz. in acquired defects of the palate, the results of syphilis, traumatism, or surgical operations involving extensive loss of tissue—as, for instance, after excision of the superior maxilla: obturators are almost invariably the only means by which these apertures can be closed. In cases of congenital cleft where the os incisivum has needed removal, leaving a broad anterior opening the closure of which by operation is often impossible (p. 135), the application of an obturator is similarly advisable; and one suggests this method of treatment the more readily from the ease with which it can be effected, inasmuch as it merely necessitates an extension backwards of the plate which carries the artificial incisors. The communication between nose and mouth is thus effectually closed, and the functional success of previous plastic work and subsequent educational efforts ensured. In cases of hopeless deformity, where the palatal tissue is so attenuated that operative interference is impracticable, the recourse to artificial assistance is inevitable; but such cases are fortunately rare. CHAPTER VIII. RESULTS OF TREATMENT—AFTER-TREATMENT.