of the urates in the urine (Lond. Obstet. Trans., vol. x., p. 168). But if these urates be not due to waste of muscle, there must then be an important significance in the fact, that puerperal eclampsia and puerperal chorea present conditions of the urine precisely opposite to each other.

The theories with regard to the nature of this remarkable disease are so far unsatisfactory, that they do not naturally accommodate themselves to all the phenomena. It has been remarked by many eminent observers (Vide article Chorea in Diseases of Children, by Meigs and Pepper) that chorea and rheumatism are frequently associated together; and this fact, together with the frequent discovery of minute bead-like vegetations fringing the borders of the mitral valve and of its leaflets, has given rise to the theory of embolism as a cause. In other words, that chorea depends on the plugging up of the small arterial branches supplying sensori-motor ganglia, thereby interfering with their perfect nutrition. But may not the intercurrent rheumatism, so frequently observed in chorea, be nothing more than the inflammation of joints and muscles produced by the excessive fatigue arising from the constant

movements?

Per contra, the opponents to the embolic theory— among whom Vogel, Barnes, and Ogle stand prominent -contend (a) That since these vegetations are so minute, and so slightly adherent as to be detached by a camel's-hair brush, they are mere blood fibrin deposited during the agony of dissolution. (b) That the unilateral character of this disease, and its usual termination in recovery,

militate against this theory. (c) That if rheumatic embolism were the cause, chorea should not so commonly be a disease of childhood, and of females. (d) That since the most frequent exciting cause is that of sudden terror, how can an emotion produce embolism? (e) That the spanæmic condition of choreic patients; the happy influence of the appearance of the menses, as in chlorosis; the contrary effect produced by pregnancy, when the albuminous basis of the blood constituents is below par, all point to impaired nutrition as a cause, rather than to embolism. Finally, that, in the present state of our knowledge, the most natural explanation is this: that the choreic movements are reflex phenomena, due to impaired nutrition of nerve-centres from impoverished blood; that the disturbance is at first merely functional, but may ultimately develop into organic lesions of the nerve-centres through the effect of prolonged irritation and shock.

PLASTER-OF-PARIS IN THE TREATMENT OF TALIPES IN INFANTS.

BY BENJAMIN F. DAWSON, M.D.,

Physician to the New York Dispensary for Diseases of Children; Asst. to the Prof. of Diseases of Children in the College of Physicians and Surgeons, N. Y.

I AM fully aware that with very many in the profes sion the use of plaster-of-paris in the treatment of the different varieties of talipes is a method they have frequently resorted to, but I think I am not mistaken in stating that the greater majority only use such a dressing

subsequent to the operation of tenotomy, as a most admirable means for keeping the foot in the rectified position allowed by division of the faulty tendons.

To Dr. James L. Little,* of this city, the credit is due of having been the first to suggest the plaster-ofparis dressing as possessing peculiar advantages over any other for application in cases of club-foot "after tenotomy has been performed." A year subsequent to this suggestion, Dr. Little first put it into practice in a case of talipes varus, after dividing the tendo-Achillis. In 1863 Dr. Enos, of Brooklyn, published a paper in the Transactions of the State Medical Society on "Deformities of the Feet, and their Treatment with Plaster-ofParis," and in which he stated that he was not aware that this form of dressing had ever been used or recommended for talipes, whereas the fact was he was anteceded, as shown above.

Notwithstanding that this method was thus prominently brought before the profession, it nevertheless seems to have lacked advocates, which is the more strange, as plaster-of-paris was and is extensively used in the treatment of fractures.

In the various text-books on general surgery no mention is made of this dressing in treating of talipes, and even in so recent a work as the last American edition of Erichsen's Science and Art of Surgery the subject is left untouched.

Holmes, in his excellent work on "The Surgical Dis. eases of Children," makes no mention whatever of club

* American Med. Times, Dec. 7, 1861, vol. 3, p. 369.

foot, evidently deeming it a subject that does not come within the scope of such a work.

In 1867* Dr. Little again came forward with another paper on the use of the "plaster-of-paris shoe" in talipes, after division of the tendons, in which he records satisfactory results in eighteen cases. In the same year Prof. Thos. M. Markoe, he states, "applied it to a case of double talipes varus, in the New York Hospital, after division of the tendons, and the result was all that could be desired."

Prof. Lewis A. Sayre, in his "Manual of the Treatment of Club-foot," just published, devotes only a short paragraph to this method, and concludes by saying: "The objections to this plan are, the weight of the dressing, the impossibility of inspecting the limb, and of applying to it friction, electricity, etc." These objections, I am forced by my experience to say, are more so in words than in facts. In the first place, instead of being weighty, the plaster-of-paris dressing is the lightest of any appliance for club-foot, as may be proven by comparative weight; and in the second, if the dressing is properly applied, the limb can be as readily and thoroughly inspected, rubbed, etc., as with any other appliance. Further, the plaster-of-paris dressing pos sesses these great advantages over all other methods: it is cheap, and the materials are readily obtained; it may be applied directly against the skin of a new-born infant without injuring it in the slightest; it fits more accurately than any other appliance; it never yields or

*New York Med. Record, Feb. 1, 1867.

becomes loosened or displaced when well applied, and is easily applied and removed.

To still further prove that the plaster-of-paris dressing has been rarely tried, I refer to an article on "The Treatment of Club-foot by Direct Extension, by Jolliffe Tufnell, Esq., F.R.C.S.I., etc., Surgeon to the City of Dublin Hospital," which appeared in the Dublin Quarterly Journal of Med. Science for November, 1869. In this paper Dr. Tufnell remarks: "I have in the course of practice used many of the various instruments made or sold for this purpose, and with each and all I have found the same objection to exist, namely, that the heel, especially in a very young patient, soon becomes retracted, and the foot to a great degree misplaced; and that, instead of occupying the position into which it has been carefully and apparently effectually placed a few hours before, it is, when examined, found to be shifted and changed." From these remarks it is decidedly apparent that the plaster-of-paris dressing had not been tried, for it is hardly necessary to state that when once hardened such an appliance is almost perfectly immovable and unyielding, and it is an impossibility for either the heel to retract or the foot to be misplaced; and as the plaster, when properly mixed, takes but a few moments to "set," it is an easy matter to keep the foot in the position desired until the hardening is complete.

The apparatus devised by Dr. Tufnell is certainly a very ingenious and simple contrivance, but, being an "iron splint," probably has the disadvantages of weight and difficulty of so fitting it as to prevent undue pressure or excoriation of prominent portions of the child's foot,