period the body is deve.oping, and it seldom shows itself for the first time late in life. At first it may not be noticed that the pains are confined to one side only, but as the attacks gain frequency and severity, it is apparent that they are limited to the distribution of one nerve, or a single branch of it, generally in one eye or half the forehead. It is possible for both sides to be affected at once or in alternation, but these cases are rare.

There are two well-marked varieties of this disorder which differ in symptoms and methods of relief, and are known as the congestive and the anæmic forms. The so-called bilious headache may exist with either.

The congestive variety is a very frequent affection, especially among those who overtax the brain and take too little out-door exercise; and its most prominent symptom is insomnia, indicating cerebral congestion. Even when the pains are not severe it is generally felt most of the time. It may be so intense that the sufferer is unfit for any mental or physical exertion, or it may be only a dull ache which is extremely annoying.

In the anæmic variety the cause is a deficiency in the amount of the red globules of the blood, as shown by the paleness of the face and lips. The pain is situated in the higher parts of the head and forehead. There is a tendency to faint on prolonged exertion, or sudden shock to the feelings, such as frights, etc. Sometimes it is of the peculiar character described as hysterical.

In either variety of this affection, we find that if the pains last long and are intense, nausea and vomiting are certain to occur. The pain is at first made worse by the efforts of nature to relieve the stomach, but these mark the worst period of the attack, and are followed by relief and sleep. When the patient awakes the pain is generally absent, but if the attack has been a severe one, there is a feeling of soreness and tenderness over the skin of the parts affected, and this may last for a day or two. The attacks may begin with a chilly sensation, yawning and sighing, like the beginning of a malarial attack, but the other signs of malarial poison are absent, and the remedies that control ague do not cure sick headache. Many patients of this kind see peculiar appearances of light before the eyes that have no existence in fact, and are known by the victim to be symptoms of the coming headache after he has experienced them a few times. These are fiery circles or sparks, or a spiral glimmer seems to present itself to the vision. In congestive headache we find the

affected side of the face is reddened, hot, and manifestly more full of blood than the other side. The white of the eye is reddened, the tears are secreted more abundantly, and the pupil on that side is contracted. The pulse may be remarkably slow in this form, running as low as forty-five beats per minute. In the other variety, we find the affected side of the face is cold, pale, and shrunken, the pupil of the eye dilated, the eye itself being sunken, and coughing, sneezing, etc., increase the pain. If pressure be made upon the carotid it also increases the pain, while in the first variety the effect is exactly the reverse. As the attacks pass off, the face resumes its natural appearance. This disease may continue to appear in paroxysms during the entire lifetime, but the attacks are further apart and less severe after the period of middle life is passed. The duration may vary from a few hours to several days. The intervals are usually free from pain, and the prospects of permanent cure are not very good, as the treatment of sick headache has as yet never produced many brilliant results. This is especially true where there is a distinct history of a hereditary nervous tendency existing in the ancestry. Many cases can be helped only temporarily. In the congestive variety ergotine is sometimes very efficacious. The bromides are also invaluable in the treatment, especially bromide of lithium, which will produce sleep and rest to the brain in smaller doses than the others. Ice applied to the nape of the neck, abstinence from alcoholic liquors and tobacco, exercise in the open air, etc., are also indicated. In the anæmic form, nitrate of amyl in small and frequent doses will often cut short an attack, to be followed by the administration of ferruginous tonics. The galvanic form of electricity sometimes relieves, and if continued for a time may effect a cure. But there is a vast deal claimed for this agent by its enthusiastic advocates that cannot be verified by the most competent operators, who are not carried away with a monomania on the subject. Cannabis indicus given persistently produces a cure in some Inhalations of chloroform and ether are too dangerous to be intrusted to the sufferer for self-administration. The same can be said of chloral, cocaine, and the various forms of opium, such as morphine, etc., as their continued use may lead to the formation of habits destructive to both mind and body. Caffeine, the active principle of tea and coffee, is a safe and efficacious remedy for the patient to use. In its combination with other chemicals it usually moderates the attack at once, and may cut it off entirely if taken early. The

cases.

hysterical headache, in which the pain is confined to a very small point, such as can be covered by the tip of the finger, can be relieved in the same way as the others by application of similar remedies; but in attempting to produce a permanent cure, the treatment should be that appropriate for hysteria in general. All sources of nervous exhaustion should be removed, the best of diet and moral influence should be given, and every means taken to insure exercise without fatigue, and effective digestion; this treatment to be continued a sufficient length of time, to show that all the symptoms have disappeared and the causes removed. Like all the neuralgias, as the renowned Anstie has well said, "it is the cry of the starving, suffering brain and nerves for healthy blood, and they are caused by the presence of poisons in the blood, derived from the growth of diseased germs which irritate and burden the brain, so that it cannot act in the natural way." Early in this affection it is often difficult, if not impossible, to say what the headache means; but close observation for a few days generally clears up all doubts.-WILLIAM H. MAY, M.D.

CLEFT-PALATE.*

THE affection known as cleft-palate while not met every day in general practice, still is common enough to demand the attention of the surgeon. It may be simply a division of the uvula or velum palate, or it may be so extensive as to involve the bones of the roof of the mouth, upper jaw, and nose. The first, or division of the soft parts of the palate, is usually the result of disease, while the separation of the bony structure of the palative arch is almost always congenital; this last you will usually find accompanied with that unsightly affection known as harelip. Sometimes you will find a cleft-palate which is the result of syphilis or its mercurial treatment, and sometimes by ulceration, the result of catarrhal inflammation, though this last is exceedingly rare.

A cleft, the result of disease or a wound, rarely involves the lip, but is confined entirely to the soft and hard parts of the palate. As a rule it is easy to distinguish between a cleft that is congenital and one that is caused by disease, as in the latter case the edges are

* Read before the West Side Medical Society.

ragged and irregular, while in the former they are generally smooth and even.

The diagnosis of the case is exceedingly simple. The first intimation of anything wrong that the mother or nurse has, is by noticing the peculiar nasal twang to the child's crying, or after a short time its inability to properly take the breast, and then on looking in its mouth the defect is discovered. Of course where there is a concomitant harelip the attention is immediately directed to the mouth and the fissure is easily seen.

If the case comes into the hands of the surgeon while the child is still young and the bones are in a pliable condition, the hope of a complete cure is greater than if it is neglected until they are of a harder consistency. A congenital fissure, if it is a narrow one, may sometimes be instantly corrected; and at other times it is so wide that the cure is affected slowly. To accomplish this result a mechanical appliance, some kind of clamp (a modification of a Hoey arterial compress or a Hainsly compress), must assist the surgeon.

Everything being in readiness, and the patient in the proper condition, the edges of the cleft, both in the soft and hard parts, are pared, cutting forward towards the lip. After the hemorrhage has been controlled, if an anasthetic is used, the little patient is reetherized, the compress is applied, and the bones gradually forced together, the parts are held in place by compresses placed upon and below the molar bones, and held by adhesive strips after the manner of Mayo's occipito-labial cravat.

It may be thought by some that this mode is rather too heroic on account of the pressure used, and that fractures or other accidents may result. This, of course, is for the surgeon to decide for himself. A bungling operator will generally do damage in the simplest of cases. I think that by care no adverse result will occur, and even if there should be a fracture, the bones are held, as it were, in splints and a union soon takes place. The only thing of consequence to guard against is inflammation,—but what surgeon does not take greater risks for far less results?

Another method that may be considered less objectionable is to get a ring of elastic tubing long enough to reach almost from one molar bone to the other, then fix the ends by means of adhesive strips and let it pass over compresses; the gradual tension tends to draw the bones to a common centre, that is, the mesial line of the palative arch. After the bones meet, then pare the edges and join

them by sutures. The only objection to this method is the irritation the rubber band is apt to produce on the delicate skin; yet this can easily be controlled.

After the bony parts are made to join, the soft parts should be attended to by paring the edges and joining them with the interrupted suture; then if the lip is also involved, it may be remedied by the usual methods. But the lip ought not to be interfered with until after the palative difficulty is remedied.

When the patient comes to you after the bones are set and the fissure is a wide one, the only remedy that is likely to prove of any avail is an obturator or artificial palate. This you can have made by any good dentist or oral specialist. Of course in a syphilitic patient this may be somewhat risky, as the parts are apt to be irritated by the plate and serious inflammation ensue.

You will find some partial clefts or holes in the roofs of the mouths of old or middle-aged people caused by wounds that can be treated only in this way. If the fissure or hole is not too large, the membrane may sometimes be dissected away from the bone and the edges pared and brought together, or in some cases the edges may be touched with tincture cantharides or tincture iodine, preferably the latter, when granulations will fill up the space. Some large holes and clefts may be cured in this way by making a plate to fit the roof of the mouth, which will give support to the granulations until the hole is entirely covered over.

Where simply the soft parts are involved in the cleft, then the edges must be pared by means of scissors or a scalpel, the free edge being held with forceps or tenaculum to enable a clean straight cut to be made; the edges are then brought together and held with the interrupted suture, three usually sufficing,-silver wire is the best to use, the ends being held either by twisting or by means of small shot-the latter is the best. Sometimes it will be found advisable to divide one or more of the palato-pharyngeal muscles. Still this is as the judgment of the operator dictates.

The food of the patient after the operation must necessarily be of a kind to require no chewing: soups, teas, custards, and anything that is nourishing but of a soft or fluid nature.

One thing you must not forget to impress upon the minds of your patients or their friends, and that is, perfect speech will come slowly and in some instances never. If you do not do this, they will expect perfect speech in a few days; and then, being disappointed, will blame you and wrongly criticise your work. THOMAS CONRAD, M.D.