curred from cerebro-spinal meningitis in Massachusetts, 747 of them in 1873 alone, leaving an average of 130 fatal cases for each of the other nine years. Suffolk County has returned 476 deaths, Middlesex 412, and Worcester 240, but there has been a steady though small rate of mortality from this cause in most of the cities and many country towns in all sections of the State except Cape Cod and the islands, where it has been trivial. For the last two or three years the number of deaths has increased moderately, namely, to 157 in 1881, and 166 in 1882, the distribution in 1881 being chiefly as follows: Middlesex County, 27; Suffolk, 24; Hampden, 21; Essex, 19; Worcester, 14.

The valuable Mortality Tables of the State Board of Health, published weekly in the JOURNAL, show that neither of the diseases mentioned above, smallpox, scarlet fever, and cerebro-spinal meningitis, has prevailed during these years to an alarming extent, the epidemic type having been mild, but the seed has still lingered in our midst, and is wide-spread, cases of cerebro-spinal meningitis cropping up from time to time among the susceptible in such a way as to suggest the probability of a future outbreak whenever the mysterious combination of influences occurs on which such visitations depend.

The remaining fundus of each eye was entirely normal; no isolated patches of atrophy, no change in the circulation, no whiteness of the nerves. With 13 D concave the left eye had vision one tenth, the visual field being not contracted. The right eye had no perception of light whatever, either when tried by the mirror of the ophthalmoscope, by a lighted candle in a dark room, or exposed to the full glare of sunlight. The pupil of this eye was most active, contracting and expanding under light and shade, the other eye of course being closed.

What was the diagnosis? The first suspicion was naturally of malingering. The perfect honesty and simplicity of the patient went far towards removing this, and the usual tests with prisms showed the entire correctness of her statement. There were no other symptoms to encourage the diagnosis of hysterical amaurosis, no signs of general hysteria, of nervous derangement, of affections of other organs of special sense, or of local hyperæsthesia. All ophthalmoscopic indications were wanting. The ready response of the pupil to light and shade showed the deep-seated character of the affection, and that, according to Flourens, ic must be located beyond the corpora quadrigemina; hence that it was likely to be diffused through a considerable portion of the brain. Such affections, says Leber, may occupy a region the integrity of which is essential to the maintenance of life itself. When the

BY HASKET DERBY, M. b.

THE following case is both so unusual, as to occurrence, and so unexpected, as to result, that I have thought a brief report of even the scanty details I have at my command might not be without interest.

October 13, 1883, I saw Mary T., aged fifteen, for the first time. Near sighted since early childhood, she had grown steadily more so during her school life, and was using spectacles, right -9.5 D, left -8 D, all the time and for all purposes. A close, ambitious student, and attending a public school, she had worked unremittingly for the past year, making her studies her principal object in life, and paying little or no attention to her general health. This, however, had ordinarily been very good, with the exception of catamenial irregularity. The flow commenced at the age of thirteen, and had never been present oftener than once in two months. She was large for her age, and apparently neither nervous nor imaginative. Since the spring of this year she had, for the first time, been subject to severe headaches, not attended by nausea, extending over the whole head, lasting both day and night, materially worse during this fall. She came to me on account of failure of sight, which had been coming on for two weeks. Observing that her eyes were watering and her vision blurry, she had covered her left eye, and ascertained, to her astonishment, that she could not see with the right. Since making this discovery, a fortnight ago, the left eye had rapidly lost ground, and she was now unable to continue her studies.

The eyes were prominent and the pupils large, but presented no abnormal appearance to external inspection. Ophthalmoscopically there was a large, but defined and apparently non-progressive sclerotico-choroiditis posterior surrounding each optic entrance. 1 Read before the Ophthalmological Section of the Suffolk District Medical Society, January 29, 1884.

to him, is always grave. Should, in a short time, however, no affection of the general health occur, the chance of an ultimate restoration of sight is encouraging, the probability then being that there is no gross material lesion, but a local derangement that may readily disappear.

Four days later the condition of the patient was wholly unchanged. Entirely at a loss as to diagnosis, but in the hope that a possible derangement of the cerebral circulation might be connected both with the headache and the loss of sight, and if so, be affected by a local abstraction of blood, I applied the artificial leech to the right temple, removing an ounce aud a half of blood. Lactate of zinc was also ordered in moderate doses.

The next day showed a result as remarkable as it was unexpected. The headache, which had been continuous and severe for six months, disappeared after the cupping, and has never since returned. Five days later there was distinct perception of light in the right eye, and even ability to follow the motions of the hand, held close to the eye. The cupping was now repeated, and again applied a week later. During this time each eye steadily gained. October 30th the right eye, armed with -12 D, had vision four tenths. The left, with -13 D, had two tenths. Each visual field could now be taken, and was found to be normal. November 6th there was

o. d. V 0.5 nearly. o. s. V 0.4.

and this amount of vision continued when I last saw the patient, December 8th. In her own opinion her sight had fully returned. Her health was perfectly good, and she was wholly free from headache. Except for the high degree of myopia, and consequent imperfect vision, each eye seemed normal. She returned to school early in the present year.

None of the ordinary causes of cerebral amblyopia seem to have been active here. The termination of

the case, of course, forbids the supposition of organic change at the base of the brain, of apoplexy, of a tumor, or of meningitis. There had been no suppression of urine. There was no suspicion of spinal disease. There had been, beyond the headache, no antecedent sickness. Finally, there was no ophthalmoscopic change, save the choroidal atrophy.

That the headache was in some way or other connected with the blindness seems probable, and that the sudden disappearance of the headache is due to the application of the Heurteloup cannot reasonably be doubted. This much-neglected instrument never entered into the armamentarium of the Vienna school of ophthalmology, much as its use was insisted on in Berlin. It is, I imagine, seldom if ever used by the majority of those here present. Of course it has no advantage over the old cupping apparatus, save in the greater facility of application to a region like the temple, particularly in the case of females. I think its disuse among ophthalmologists is seriously to be regretted. It was much employed and warmly advocated by Graefe, especially in cases of congestive amblyopia and chronic affections of the choroid; in fact, in all cases where a rapid evacuation of an appreciable amount of blood was indicated, but not, of course, in those forms of external ophthalmia where the prolonged and slow flowing of a steady stream is productive of decided benefit.

Local cupping has in our day seemed to share the fate of general venesection, a therapeutical method of value when judiciously used, greatly abused by routine practitioners, but whose total neglect is a distinct loss to medicine.

AN IMPROVED APPLIANCE IN THE PHYSIO-
LOGICAL TREATMENT OF CLEFT PALATE.1

BY HENRY A. BAKER, D. D. S.,
Lecturer on Oral Deformities, Boston Dental College.

IT has usually been said that lesions of the palate arise from one of two causes, that is, they are either congenital or accidental.

Congenital cleft of the palate was as commonly treated surgically as by mechanism. The former treatment has been nearly or quite abandoned in recent years for two very good reasons: First, it is a very painful one for the patient, and difficult for the operator, and a failure of closure is largely in the majority. Second, it universally fails to improve the speech even after a successful closure.

Notwithstanding the above facts some physicians recommend staphyloraphy. They must certainly do so from want of knowledge of the anatomy and physiology of the vocal organs and their use in the mechanism of speech, which is the production of sound, and its direction through the nasal passage or the mouth at will, being controlled by certain organs whose modification and resonance enable us to form what we term articulate speech.

One of the most important aids in producing the above results is the soft palate. This organ is lifted up and comes in close contact with the pharyngeal wall, thus shutting off the nasal passage, which is absolutely essential in producing all excepting nasal sounds. After the operation of staphyloraphy such a

1 Read before the Section for Clinical Medicine, Pathology, and Hygiene of the Suffolk District Medical Society, December 12, 1883.

closure is impossible, owing to the soft palate having been made too short and tense, hence defective speech invariably follows.

Accidental lesions of the palate, as the name suggests, are caused either by accident or disease. These cases may be successfully treated with a very simple. appliance, while the same amount of skill exercised on a congenital cleft would have no beneficial result. This may be accounted for by the fact that in the former case the patient had learned to articulate distinctly, and use the organs of speech efficiently and correctly, while persons who are thus deformed from birth are obliged to learn the art and methods of articulation by slow and painful processes. The organs require the training which is necessary for one who acquires a new language. Hence the appliance for relief should not only fill up the gap in the defective palate, but should also be so constructed as to work on physiological principles in harmony with the natural movements; that is to say, it should be under perfect control of the surrounding muscles. It is manifest, therefore, that the success even of the most scientifically adjusted instrument depends largely upon the coöperation of the patient who uses it.

As the above malformations are classed as congenital, and accidental, the appliances for their relief are classed as follows: obturators and artificial vela. Among the former Dr. William Suersen is the inventor of one which has created much interest. The most important and significant advance in this department of science, however, made itself manifest in attempts to form an artificial velum, and Dr. Stearns was probably the first to introduce its true principle. I speak of these two investigators, Suersen and Stearns, because I am led to think that they have brought before the profession the most scientific apparatus of each class, and it is from a consideration of both of their appliances that I have evolved the principle, in explanation of which this paper has been prepared. Suersen says: 66 In order to be able to pronounce all letters distinctly it is accordingly necessary to separate the cavity of the mouth from the cavity of the nose by means of muscular motion. That separation is, under normal conditions, effected, on the one hand, by the velum palati, which strains itself (consequently by the levator and tensor palati), but, on the other hand, also by a muscle, which to my knowledge has not yet received a sufficient amount of attention in connection with these operations. I mean the constrictor pharyngeus superior. This muscle contracts itself during the utterance of every letter pronounced without a nasal sound just as the levator palati does. The constrictor muscle contracts the cavum pharyngo-palatum, the pharyngeal wall bulging out, and it is chiefly on the action of this muscle that I base the system of my artificial palates."

It will be noticed that Suersen admits that the levator palati is an important organ of speech, yet he makes no provision for utilizing it as such, and only provides for the superior constrictor muscle coming in contact with the distal surface of his appliance to shut off the nasal passage. In my opinion, for the patient afflicted with congenital cleft to acquire perfect articulation with such an appliance (even if it be possible) years of application and training of this muscle would be necessary. A little reflection will show that this muscle, besides performing its own function, must be trained to fulfill those of the velum palati, levator palati, and

tensor palati. But in an accidental lesion this may be all that is necessary, as the patient having previously learned to articulate distinctly, and having this deformity come upon him afterwards, the superior constrictor muscle would, no doubt, be sufficiently developed to perform that function.

Sir William Fergusson, in his report of a dissection made by him of a cleft palate in 1844, states distinctly that the superior constrictor was very full, and he also claimed for that muscle very decided forward action in deglutition. It was in the year 1841 and 1842 that Dr. Stearns made his first artificial velum. In 1860 Dr. N. W. Kingsley came into the field, and took up Dr. Stearns's appliance. Finding it too complicated for the general practitioner to construct, and too expensive when completed for those in ordinary circumstances, he was led to serious thought in regard to modifying its production, but he still adhered to the same principle of utilizing the levator muscle.

Dr. Kingsley says respecting Dr. Stearns's appliance: "Two principles were vital to Dr. Stearus's instrument, namely, first, the artificial velum should embrace the levator muscles of the palate, so that it could be lifted by them; and, second, that it should bridge the upper pharynx behind the uvula, and cut off nasal communication at will."

Dr. Kingsley's modification of Stearns's instrument consisted chiefly in leaving off the triple form, and doing away with the central slit, the flap, and the springs. The simplified form consisted of two leaves of soft vulcanized rubber, connected in the median line, the palatal portion running down to the uvula, and then bridging across at that point, and the nasal portion reaching across the pharynx. Instead of the appliance being made in sections so as to slide across each other, as in the Stearns, the bifurcated uvula slides between the two leaves, and the levator muscles of the palate lift it up to meet the pharynx, thus shutting off the nasal passage. It will be noticed that in this simplified form the Stearns principles are fully carried out, and to Dr. Kingsley that credit is due. His claims to originality are in the simplifying of the Stearns instrument.

Dr. Kingsley says: "An important principle enunciated by Dr. Stearns as essential to the success of all artificial vela for congenital cleft was that the instrument filling the fissure in the natural palate must be of the nature of a valve under the control of the muscles surrounding it, and so arranged that it could be elevated by them, thus shutting off the nasal passage, as is absolutely essential in the production of certain sounds belonging to articulate language. This principle was carried out by him first in the character of the material chosen, being of a yielding, elastic nature, and second in the form, being made to embrace the levator muscles, and subject to their control."

Dr. Kingsley in speaking of Suersen's appliance says: "First, that of all obturators this is the best form for a congenital fissure, but while the wearer is enabled to articulate with such an instrument it is only after he has learned articulation with another apparatus. Second, that a soft, elastic, artificial velum is much better adapted to the acquirement of articulation than any unyielding, non-elastic substance, but when acquired an obturator may be substituted. Third, that in very rare cases articulation may be acquired with an obturator only, but it is the result of the extra activity of the pharyngeal muscles, while with the

elastic velum the levators of the palate contribute largely."

A great many practitioners in treating a fissured palate simply separate the nasal and buccal cavities by a thin plate, thinking that the separation is all that is required. Some even make a great parade of this device, claiming it to be an improvement over any other appliance. A little reflection will show this to be impossible, as I shall endeavor to explain before closing this paper.

My own experience with soft vulcanized rubber for an artificial velum is that if it would resist the fluids of the mouth, and not go through a process of decay, and change its form, in short, if it could be made permanent, it would be all that could be desired. Since this is impossible I do not hesitate to say that it is a very objectionable material, and I have been led to long and careful meditation regarding it.

I experimented for five years to provide an artificial appliance with hard rubber, carrying out the Stearns principle, whereby I could utilize the levator muscles to control the movement of the appliance, and with which articulation could be learned as well as with the soft rubber. My studies and experience induced me to settle upon the following device, which consists of a

gold or hard-rubber plate (A. Fig. 1), covering the roof of the mouth down to the junction of the hard and soft palates. From this point the artificial velum, F, extends back and downward, restoring the symmetry of the palatal surface by bridging across and lying upon the muscles of each side. The distal surface, G, or that portion coming in contact with the pharyngeal wall, is quite broad, and so constructed as to articulate perfectly with this surface, while the constrictor muscle contracts and closes around it on a semicircle. This is the Suersen principle, and the main ideas I take from that appliance.

The velum is of polished hard rubber, gold, or platinum, and much resembles a chestnut in form.

It is attached to the plate with a hinge joint, B, B, thus giving free movement at the junction of the hard and soft palate. At the junction of the hard and soft palate there is a stop, which prevents any downward pressure upon the muscles when in a relaxed condition.

The bulb-like form of the velum (see D, Fig. 4) necessitated a thickness which would naturally have made it quite heavy, and, as the resultant weight would be a serious objection, I was desirous of overcoming the difficulty. A suggestion happily came to 1 The accompanying cuts are kindly loaned by Dr. J. W. White, the editor of the Dental Cosmos.

my relief in this way: While in a drug store I accidentally took up a hard rubber, truss made by a Philadelphia firm. Discovering that the pad was made

which illustrate this article was made so light that it would not sink when put in water.

In treating a case by Kingsley's method I was obliged to use a hinge-joint to bridge over a union by staphyloraphy. I found in that case that the appliance was much better controlled by the surrounding muscles, and saw a much more rapid progress in acquiring articulate speech. This led me to more fully provide for that muscular movement, and I will endeavor to give the reasons why this should be done. As we have before quoted from Suersen, in order to pronounce all letters distinctly it is necessary to separate the cavity of the mouth from that of the nose by muscular action, and to close the nasal passage in pronouncing every letter, except me and n. This can be demonstrated by holding the nose while endeavoring to pronounce all the letters as plainly as possible.

In studying the mechanism of speech we learn that more than three fourths of the sounds of articulate language depend upon the integrity of the soft palate for their perfect enunciation. This being the fact, articulation with a rigid obturator must be extremely difficult to acquire. If three fourths of the sounds depend upou the free movement of the natural palate, it seems to me a sufficient reason why we should provide for that movement in an artificial one.

Dr. Kingsley says that with a yielding appliance

speech. The surrounding muscles have control over my appliance in the following way: The artificial velum bridges across the opening and lies upon the muscles of either side. (See Fig. 3, D, D.) With all sounds requiring the closure of the nasal passage it is thrown up (D, Fig. 4) by the levator muscles, there being no resistance. The thickness of the velum brings its posterior surface in close apposition with the superior constrictor muscle, F, and thereby affords, in the pronunciation of the gutturals, a firmer resistance to the pressure of the tongue, G, than can be obtained with a thin obturator. By the presence of the hinge, B, the above movements are rendered so free and easy

FIG. 3. Appliance in position: A, the plate; B, the stop, preventing any downward pressure when the muscles are in a relaxed condition; C, the artificial velum; D, D, muscle lying under it, the dotted lines showing the appliance resting on the muscles.

hollow, I thereupon wrote to the manufacturers, asking them if they would inform me how they prepared the rubber in that way. In their reply I found that the method was quite simple. It is as follows: Take the vulcanite rubber in the soft state and cut the sheets so that when joined together the desired form is given. Then a little water is dropped into the cavity (I found it better to add a little alcohol), the edges are sealed, and the piece vulcanized in the usual way. The steam produced by the water and alcohol inside creates sufficient pressure to keep the walls distended. By this method the appliance that the cuts were taken from

FIG. 4. The artificial palate thrown up by the muscles, E, E, as in all sounds requiring the closure of the nasal passage; F, the superior constrictor muscle advanced to meet it; G, the tongue, raised, pressing hard against the appliance, as in pronouncing the letter k or g; A, the plate; B, the hinge joint and stop. that there is no tendency to any displacement of the plate, such as occurs with a rigid appliance. If a nasal sound immediately follows a guttural, the descent of the velum is rendered certain by its own weight. (Fig. 5, D.) My first instruments show a spring bridging over the hinge, by which I intended to accellerate the movements of the velum. This I found later to be unnecessary.