process. The operation succeeded perfectly, but the child died on the sixteenth day, from diarrhoea and aphthæ. The cicatrix was found to be admirable, and the separation of the bones was so much lessened, that, had death not occurred, the fissure would undoubtedly have been quite obliterated. Baudon has operated, and with success, in a case of double hare-lip and fissure of the palate, in an infant aged four days. He operated first on the right, and at the end of a fortnight on the left side. Andrew Nolan records (Dub. Med. Press, 1853) a suc cessful case of operation for single hare-lip on an infant six hours; and Bateman (Med. Times, 1854), on one four hours after birth. Mestenhauser, of Raaste, in Silesia, during a practice of thirty-two years, operated for hare-lip eighty times, and prefers the children to be at least ten or twelve weeks old before it is undertaken. Dieffen. bach has operated upon a thousand cases, and states that, while union has taken place at every age, from a few days after birth up to extreme old age, it is better to wait until dentition is accomplished, as when performed very early the cicatrix is apt to yield as growth advances.

If it were not for the supposed danger attendant upon an early operation, there could be no question at all as to the importance of remedying the defect, at the earliest age possible. The effectual removal of the deformity, and the inconvenience attendant on it, being then more easily and certainly effected than when the operation is deferred to a later period. We are persuaded with Dr. Houston, that the dangers and difficulties attendant upon early operations are greatly overrated. Several instances of the successful removal of simple harelip, at ages varying from a few days up to as many months, have been recorded within the last few years, and we have so repeatedly seen the operation performed in children, from six weeks to four months old, with perfect success, and without the occurrence of the slightest untoward symptom, that we feel it our duty to recommend its adoption very generally at the termination of the third month, or, where the deformity is very great, at even an earlier period.

The advantages of operating at a very early period, especially in cases complicated with a more or less extensive fissure of the palate, are very clearly pointed out by Henry Smith, Esq., in the number of the Medical Times for March, 1854.

16.-Club-foot.-Talipes.

Children are frequently born with various deformities of the feet, to which the popular denomination, club-foot, has been applied. The foot may either be turned outwards, so as to allow its inner margin to rest upon the ground (valgus, talipes-valgus); or inwards, its outer edge being directed to the ground (varus, talipes-varus); or the heel may be drawn up, so as to direct the toes downwards and extend the foot, causing it to approach a right line with the leg (pes equinus, talipesequinus). A fourth variety has been described by Little, in which the foot is flexed upon the leg, and the heel only is applied to the ground. This distortion is caused by a contraction of the muscles in front of the leg.

These deformities are, in general, apparent from birth, but increase in extent as the child grows older, particularly as it approaches the period when it should walk. If they are not remedied at an early period, the child is, in general, doomed to lameness and deformity for the residue of its life.

Much attention has been directed of late years, to the investigation. of the pathology and mode of remedying the various congenital distortions of the feet, by several distinguished surgeons and physicians of Europe and America. Their immediate cause would appear to be a shortening of the gastrocnemii and other extensor muscles, or of those which rotate the foot outwards.

The pes equinus, or extended foot, from shortening of the extensor muscles, is probably the most common form of distortion, the twisting of the foot inwards being produced secondarily, in consequence of the natural inclination of the os calcis, and the normal action upon this of the gastrocnemii, causing the foot to turn somewhat in that direction. As the turning inwards of the foot increases, the plantar muscles, ligaments, and aponeuroses become more and more contracted, the deformity increases, and first, the side of the foot, and finally, its dorsum, is applied to the ground. The bones of the tarsus are at the same time thrown into an unnatural position, and after the child begins to walk, being subjected to continual pressure, become altered in shape, in consequence of which the deformity, which in the first instance, might, with due care, have been removed, becomes permanent. The twisting of the foot outwards, which is of comparatively unfrequent occurrence, is produced by a shortening of the abductor muscles.

The remote cause of club-foot is to be referred to a defect in the nerves distributed to the muscles of the leg, in consequence of which there is a want of balance in the development and action of the antagonist muscles.

Distortions of the feet have been met with in foetuses of from three to five months, with coexisting deficiencies, and malformations in the brain and spinal cord; in anencephalous and hemicephalous embryos, the hands, as well as the feet, have exhibited similar distortions. Chil dren born with a deficiency or disease of the spinal marrow, are also very commonly affected with club-foot; the deformity is hence a com.. mon accompaniment of spina bifida. It may also take place subsequent to birth, when, from disease of the spine, temporary paralysis of the muscles of the extremities is produced, and on a partial reco very taking place, the flexor muscles acquire more power than the

extensors.

Distortions of the feet are said to be hereditary, in consequence of the transmission of a morbid irritability of the nervous system, predisposing to convulsive and spasmodic contractions of the muscles. We have no doubt that this may occasionally be the case, but of all the numerous instances of club-foot that have fallen under our notice, no one occurred in children born of parents, either of whom were similarly affected.

In the treatment of club-foot, the grand object to be effected is to extend those muscles, the inordinate contraction or shortening of

which has produced the distortion, and to increase the action and power of their antagonists. The first must be effected by mechanical contrivances, adapted to preserve the feet in their natural position, and counteract the force by which they are drawn out of it; the second, chiefly by friction of the limbs, and a well-conducted general hygie nic treatment, calculated to reduce the excitability of the nervous system, and to give tone to the body generally.

A variety of mechanical contrivances have been suggested, in the form of splints, stocks, and shoes, to retain the foot in its natural position, and counteract the distorting force.

It is not within the province of the present work to present a description of these several apparatus, or to enter into a discussion of the question, as to which of them is the best adapted to effect the object for which they are employed. We would merely remark, that whatever contrivances we adopt, simplicity and lightness are of the first importance, as well as such a form as will prevent any undue pressure upon the part that is made the point d'appui.

The form of the apparatus will vary somewhat, according to the species and degree of distortion, in order to enable it to act effectually upon the shortened muscles, which should be gradually and gently, but constantly extended.

When the shortening of the muscles is very considerable, or the force they exert in drawing the foot in an unnatural position too powerful to be overcome by any mechanical means that it would be prudent to employ, it is probable that a division of the tendons may be advantageously resorted to. We must recollect, however, that such division will not be sufficient to effect a cure: in no case can this be accomplished without a long-continued use of appropriate mechanical means-while the latter alone will, in most cases, be fully adequate to produce a complete removal of the deformity, if commenced with sufficiently early, when the parts involved in the deformity are still sufficiently flexible, and the ligaments, aponeuroses, and bones of the foot have undergone no important changes, and when the confinement of the foot can be borne with greater ease than at a later period.

17. Induration of the Cellular Tissue.

Indurcissement du Tissu Cellulaire-Edema Cellularis-Skin-boundSclerema.

A peculiar hardness and tension of the skin of the lower extremities, often of the trunk, and occasionally of the face, with coldness and a yellowish or wax-like appearance, or a pale red or purple color of the affected parts, are often observed in infancy, during the first few days or weeks after birth.

A slight yellowish tint of the skin may precede for a short period the full development of the disease.

The disease sometimes commences at the feet, but perhaps inore generally about the pubic region, and inner surface of the thighs; from whence it gradually extends over the greater portion, if not the entire surface of the body. The affected parts become swollen hard,

and incompressible; the skin is tense, and adheres firmly to the parts beneath, so as not to allow of its being pinched up or moved over them; it is at the same time dry, harsh, and decidedly cold to the touch, and, in some cases, presents a yellowish, or waxen appearance; whilst in others, it is of a pale red, purple or livid hue. The swelling, according to Auvity, never occurs upon the thorax; in extreme cases, however, the tumefaction is universal.

In the latter case, the swelling is the most considerable; whilst the firmness and tension of the parts are the greatest when the skin assumes a pale yellowish color. The diminution of the temperature is always remarkable; and when the disease extends over the greater part of the surface, the body is acted upon by external heat in the same manner as so much dead matter.

Roger (Archives Gén. de Méd.), found, in 19 cases, the temperature to be less than 91°, in 7 it sank below 78°, while the mean of 52 observations was only 87.8°. In extreme cases the temperature may sink to 77°, 74°, 72°, and in one instance it was as low as 71.6°. According to Roger, the diminution of temperature precedes the induration, or at least exists in a very marked degree while the induration is still very slight. The reduction of the temperature is always in direct proportion to the degree of induration, and consequently forms an important element in the prognosis. Recovery took place in only a single case after the temperature had sunk below 90. 5°, though life was often prolonged for several days, notwithstanding a much greater reduction of temperature. The slowness of the pulse and respiration likewise bear a direct relation to the lowness of the temperature and degree of induration, the former having sunk even as low as 60, the latter to 16 or 14.

The induration as well as the tumefaction, may be confined to particular localities. Sometimes they are so circumscribed as to give to the touch an appearance of knots beneath the skin. (Hulme, Mem. de la Soc. Roy. de Méd., tome ix. Borchard, Jour. de Méd., 1858.)

The infant laboring under this disease refuses to suck; its countenance becomes pale and contracted; it is restless; appears unable to make a full inspiration, or cry out, but almost constantly makes a peculiar kind of moaning noise, which has been compared by Dorfmüller to the cry of young mice. Deglutition appears, in general, to be attended with difficulty, and is sometimes impossible. There is present, usually, a general immobility of the voluntary muscles. The mouth and eyelids are inactive. The patient lies as though in a state of stupor. There may, nevertheless, take place slight spasmodic movements of the muscles of the face or extremities. The pulse is usually small, rapid, and irregular; and there is always more or less disorder of the alimentary canal, with frequent discharges of a bright green, or whitish, or clay colored appearance. There is generally a deficient secretion of urine; to a greater extent in some cases than in others. Elsæsser has seen an abundant discharge of albuminous urine.

Respiration becomes gradually more and more difficult, until death ensues, usually before the fourth day, but sometimes not until a much

later period. In some cases tetanic spasms supervene towards the close of the disease; the head and trunk being occasionally bent rigidly backwards, and the jaws firmly locked. Dugès has observed, sometimes, a slight hiccough.

The disease is unattended, throughout, with any degree of febrile reaction; though in some cases a degree of febrile excitement may precede its occurrence. Occasionally it is accompanied with a jaundiced condition of the entire surface.

Induration of the skin in infants is an affection which is always of a dangerous character; generally terminating fatally, within one, two, or, at farthest, three weeks. In slight cases, in which the morbid condition of the integuments is of limited extent, sometimes, in a few days, the respiration of the infant improves, the parts affected increase in temperature, and become softer, and by slow degrees an entire recovery takes place.

On the examination of the bodies of infants who have died of induration of the skin, the subcutaneous cellular tissue is usually found to be thickened, condensed, and loaded with serum. It is often of a reddish or granular appearance, not unlike a portion of hepatized lung. In many cases the adipose substance is firm, hard, and indurated; consisting of solid fatty granules, easily detached. The tissue is of a deep yellow; usually from half a line to three lines thick, and sometimes below it there is a gelatinous deposit. The indurated tissue is traversed by numerous veins gorged with black blood. (Elsæsser.) This state of the adipose tissue may occur with or without infiltration of the cellular tissue. The whole of the tissues are engorged with venous blood, with which every organ is unusually loaded.

The induration seldom extends below the chorion. The muscles are pale, as if infiltrated, and in those of the buttock small deposits of blood have been found. (Elsasser.)

The most frequent lesion of the viscera is inflammation of the alimentary canal, with more or less morbid change of the liver.

In the forty-nine fatal cases observed by Elsæsser (Archiv. Gén.), the veins and sinuses of the brain were mostly filled with dark diffluent blood, and effusion was found in the ventricles or at the base. In one tenth of the cases, lobular pneumonia was present, and in a third, portions of the lungs were permeable to air. Intestinal lesions and hyperæmia of the abdominal viscera were common, and in eight cases, peritonitis was present.

The lymphatic glands are frequently found indurated and enlarged; more especially those of the mesentery. In general, the serous infiltration is not confined to the subcutaneous cellular tissue; it has been observed in the subperitoneal tissue, in the cavity of the mediastinum, and in the plexus choroides: we have met with it in the interlobular structure of the lungs, at the base of the brain, and along the whole of the spinal marrow. When free incisions are made through the skin, the serum gradually flows out, and the swelling and hardness of the diseased parts disappear, excepting in those cases in which there coexists with the serous infiltration a hardening of the adipose tissue. (Andry, Auvity, Denis, Dugès, Wolf, Billard.)