Reports of Societies.

NEW YORK ACADEMY OF MEDICINE-SECTION ON ORTHOPEDIC

SURGERY.

Meeting of January 17, 1902, George R. Elliott, M. D., Chairman.

Dr. W. R. Townsend presented a baby four months old, showing a mild type of webbed fingers. The webbed hand was smaller. The fore and middle fingers of one hand showed the web; no other congenital deformities present.

No explanation was offered to account for the extreme smallness of the webbed hand.

Hemi-hypertrophy of the Bones of the Face and Head. Dr. Townsend also presented the case of a girl four years old. The right side of the face and head seemed larger. When first seen, edematous tissue over the back of the head rendered it difficult to determine whether the bones were enlarged or not. The edema subsequently decreased, and an increased size of the occipital and right parietal bones was manifest. The frontal bone was not involved, but the right inferior maxillary bone appeared enlarged. There was no history of syphilis; lower extremities were developed. The child had an enlarged abdomen and the deformity known as chicken-breast. The exact diagnosis was puzzling; the question was whether it was leontiasis or rachitis.

The Aspiration Treatment of Abscesses. A patient was also presented by Dr. Townsend-a boy eight years old, who January 9, 1901, gave the history of hip disease of one year's duration. There was an abscess on the outer aspect of the thigh which was aspirated April 6th ; it refilled, and was again aspirated on April 29th, and again on May 11th. The abscess did not recur. The case was presented to illustrate the successful treatment of these abscesses by aspiration.

He said abscesses not interfering with application of braces and not burrowing, and those not in a condition of mixed infection, could be safely let alone or aspirated.

Dr. Nathan stated that, after careful study of the literature of reported cases of leontiasis ossea, it did not appear that there was any agreement between authorities reporting the cases as to the definite

lesions constituting this condition. All the reported cases differed from one another, and the case presented differed in many respects from all cases noted in the literature of the subject. He said that originally in the case presented there was a distinct cleft in the occipital bone. There was certainly some enlargement of the occipital bone as determined by measurements, but the hypertrophy of the soft parts over the lower maxilla made it difficult to measure that bone.

Dr. V. P. Gibney, in discussing the case of abscess treated by aspiration, presented statistics from his private records of twenty-three cases treated by aspiration, fifteen of which were cured. Of these fifteen, in three cases the aspiration was done once; in four cases, twice; in four cases, three times; in four cases, four or more times. Of the remaining eight, three were aspirated once, but the needle was large and caused leakage and sinus formation; four were aspirated twice; in one, spontaneous opening took place a few days later. In all cases where cure failed there was no damage done by the aspiration.

Dr. T. Halstead Myers expressed himself as in favor of non-operative treatment when the tubercular abscesses were not infected and were not interfering with the patient's health or threatening another joint. He had seen many cases cured without operative interference, and considered this best in dispensary practice; aspiration should be tried before more radical operative measures.

Dr. R. H. Sayre said that he had aspirated frequently and sometimes secured good results, sometimes not. He had seen many cases get well without treatment, and cited one case of recurrent abscess of the thigh; if these abscesses could not be opened and kept surgically clean he advised aspiration, and if this were not practicable to let them alone.

Dr. George R. Elliott asked Dr. Gibney if his statistics included any spinal abscesses.

Dr. Gibney replied that they referred to abscesses connected with the hip only. He further stated that he had had cases of spontaneous disappearance, but that most of the psoas abscesses had been of long duration, that had been given up under the expectant plan of treat

ment.

Torticollis. Dr. Royal Whitman presented the case of a boy twelve years of age, illustrating treatment of severe torticollis by the open

incision, with over-correction of the deformity. The operation was performed November 7, 1901, and resulted in correction of the deformity with no limitation of motion.

Dr. J. P. Fiske asked Dr. Whitman what structures were cut.

Dr. Whitman replied that all resistant structures were divided-the two insertions of the sterno-cleido-mastoid muscle and the cervical fascia being the most important.

Dr. Myers said the operation should be done early. He had seen cases left until the individual was fifteen years old, in which the sternal ends of the clavicles had been partially dislocated upward by the short sterno-cleido-mastoid; this was a difficult deformity to correct.

Congenital Anterior Displacement of the Hip. Dr. Whitman presented a girl five years old, illustrating congenital anterior displacement of the hip. He said ordinary methods of replacement were not successful in such cases, and whatever treatment was adopted must be supplemented by osteotomy of the femur, otherwise the head of the bone would be displaced when the parallelism of the limbs was restored.

. Dr. Fiske said he thought the condition should be regarded as a superior displacement rather than anterior.

Dr. Whitman replied that he understood the term congenital anterior displacement of the hip as indicating that the head of the femur was directed forward, lying below and to the outer side of the anterior superior spine.

Congenital Dislocation of the Hip Cured by the Lorenz Method. Dr. Whitman also presented a child aged three years. The non-cutting operation had been performed one year previously. The plaster bandage was worn only seven months. This illustrated the fact that in certain cases of a favorable type cure might be accomplished in a short timecure meaning both as to function and position. It was impossible to say from observation which hip had been originally displaced.

Double Congenital Hip Dislocation Treated by the Open Method. Dr. Whitman presented a patient, a girl seven years of age, upon whom he had operated by the open method three years previously. The patient now walks with but slight swaying of the body; the lordosis has completely disappeared, and the permanency of the case is assured by the lapse of time; there is practically no restriction of normal motion.

Dr. Elliott asked if the two operations were performed at the same time, and if much acetabular scooping had been done.

Dr. Whitman replied that the operations were performed about three weeks apart; the heads of the bones in this case were easily replaced, and very little scooping was necessary; he considered one advantage of the scooping was that it caused adhesions, which bound the bones more firmly and prevented subsequent displacement; the amount of scooping differed in different cases, some requiring a great deal, while in others simple arthrotomy might be sufficient. He further stated that after operation of this character the fixation bandage should be employed for many months, exercise and passive motion being useless until complete repair had taken place. In one instance he had fixed the limb for eight months, and at the end of that time the motion was far less restricted than in the majority of cases in which the restraint had been removed soon after the operation.

Phocomelia. Dr. Henry Ling Taylor presented the case of a girl five and one half years old, the second of four children; no developmental anomalies in the family. The mother stated that the feet presented, and that something was wrong with the shoulder at birth which was rectified by the physician. When the child began to walk, at fourteen months, a slight lameness on the left side was noticed, which has persisted. Motion at the hip was normal, but the left leg was two inches shorter than the right, the shortening confined to the femur; the trochanters were in normal position and the classical signs of congenital dislocation and coxa vara were absent. He offered the diagnosis of congenital shortening of the left femur, confirmed by a skiagraph, which showed the femur to be short and small. The points of interest were the differential diagnosis, the slight lameness with considerable shortening-which was the rule when the joint motion and muscular power were good-and the absence of true lateral curvature, with a markedly sloping pelvis, which was also the rule.

Dr. Elliott asked Dr. Taylor for the etymology of the word "phocomelia."

Dr. Taylor replied that it was derived from two Greek words meaning seal and limb, the combination being equivalent to "flipper deformity." The term had reference to imperfect development in length of one or more of the long bones of the extremities.

Dr. Sayre considered that the term phocomelia should be restricted. to the extreme cases in which the long bones were either absent or almost entirely so.

Dr. Taylor stated that Kummel, Klaussner, and other authorities applied the term to such cases as the one presented.

Webbed Fingers (Operation). Dr. Alfred Taylor presented a case of web fingers. The case was operated on recently, but some of the fingers were in a condition to show the results of the operation. The patient, a boy, was born with three fingers of each hand entirely webbed to the tips. On the middle and ring fingers of both hands the bases of the terminal phalanges had grown together; the little finger showed no bony union. The first operation was done in November on the little finger of the left hand. Later the entire condition of the right hand was relieved by operation. The method was to make an incision on the dorsum of one finger and palmar surface of the other, dissect up the flaps, using the opposite flaps to cover the fingers. In the little finger primary union was obtained. Instead of making a cross-cut at the base of the flap, or instead of making a V-shaped flap, the incision was simply carried the full distance up toward the web in each case; then it was found by suturing the edges together that the edge of one flap would obliquely cross the edge of the other, crossing in opposite directions, the two edges meeting in the middle. This method worked very well.

Dr. Sayre read a paper entitled "The Operative Treatment of Webbed Fingers, with Presentation of Cases."

Dr. Sayre reviewed briefly the classical methods of operation, and illustrated on a model his method of operation, by making a flap for one finger and grafting to cover the other, and taking an A-shaped flap from the dorsum of the hand, slipping it over and stitching it to the palm to form the bottom of the web. In methods which did not employ a graft from some other part of the body to cover the inner side of one finger, the effort was made to cover a defect with insufficient material, since the web connecting two contiguous fingers was much less extensive than the amount of skin which would cover the contiguous margins of those fingers normally and pass into the interdigital cleft. For demonstration, a stuffed glove of one color was slipped. inside of one of a different color, the fingers of the latter being sewed together to represent webbing after the removal of the piece of kid lying on the contiguous sides of the webbed fingers.

Dr. Myers considered grafting a great improvement over other methods in these cases. Only the bottom of the cleft need be covered by a flap.