January 10, 1905.

The President, DR. J. H. JOPSON, in the Chair.

INTESINAL ATONY IN INFANT.-An infant, two years old, was shown by Dr. D. J. M. Miller. The child had been well at birth, and as far as was known until it was weaned, at the age of ten months. It was fed after weaning on condensed milk and various infants' foods. Four months later it was placed at a baby farm, and when its mother took it back again, after an interval of several months, she noticed at once that it did not seem as bright as it should, and that the abdomen was distended. The child had been to several hospitals at different times since then, and came under Dr. Miller's care at the Children's Hospital. There was a history given of persistent diarrhea and of improper feeding. The child was rickety, with emaciated limbs, and the abdomen distended to a circumference of 23 inches. The stomach when filled with water could not be outlined, and the colon could retain a quart of fluid for some twenty minutes. Palpation failed to detect the liver or spleen or any enlarged glands or masses. Large quantities of intestinal gas were constantly being passed. The superficial veins could easily be traced over the abdomen, but their junction with the thoracic veins could not be made out. The temperature ranged between 99 and 101 degrees Farenheit. Secondary anemia was present. A few hyaline and granular casts were occasionally detected in the urine, with a trace of albumin. The possibility of intestinal or mesenteric tuberculosis was recognized, and two injections of tuberculin made; reaction followed promptly in both cases, but, nevertheless, this was not thought sufficient evidence upon which to base a diagnosis, since the reaction might be due to a focus of tuberculosis elsewhere. The presence of bronchial and intestinal catarrh of long standing made it not improbable that this focus might exist in the bronchial lymph nodes or the mesenteric glands, although it had not been detected there. The patient had improved in weight and general condition under careful feeding, massage and strichninae injections, but the mental as well as physical backwardness was marked. The child did not speak at all, and gave no sign of recognizing anyone, even those who had cared for it for a long time. The movements of the fingers almost suggest athetosis. Whether malnutrition alone accounted for the mental defects or whether the cerebral development was arrested could not be determined. Dr. Miller, while admitting that abdominal tuberculosis was possible, inclined to a diagnosis of extreme intestinal

atony, due to rickets and intestinal catarrh, and the brief discussion following agreed in general with his conclusion.

CONGENITAL OBLITERATION OF THE BILE DUCTS.-Dr. J. P. Crozier Griffith read a paper on this rare cause of icterus in the newborn, with report of a case. A child, ten days old, with a negative family history, and born at term, was brought to the hospital with severe jaundice. Nothing wrong had been noticed during the first three days after birth, meconium passing per rectum up to that time. Then the mother noticed jaundice. Some infection of the cord became apparent; the stump fell about the eighth day. The child was small and emaciated, skin and conjunctivae extremely icteric, pulse feeble and rapid; respirations accelerated. No food could be retained. Constipation was absolute, and bile present in the urine. Death took place twelve hours after admission to the hospital. The autopsy showed a complete obliterating stenosis of the common bile duct about a quarter of an inch above its opening into the intestine. The lesions characteristic of this disease consist in obstruction somewhere in the biliary passages. The bile ducts may be wanting or imperfect, or represented by a fibrous cord. They may be apparently normal but with the lumen obliterated. The gall bladder may be absent, or much dilated. The liver is generally firm, dark green or of a natural color and exhibits some lesions of hypertrophic cirrhosis. The cause is often obscure. The fact that several cases in the same family are reported in several instances would suggest a congenital failure of development. In other cases the existence of an obliterative inflammation seems probable. The chief symptom is icterus, next in importance being acholic stools. Vomiting is apt to occur, also hemorrhages from the cord. Death occurs in convulsions or sopor or from exhaustion, usually after a course several weeks or even months. There is great difficulty in distinguishing congenital obliteration of the bile ducts from other forms of severe icterus. Cases are on record with recovery, which, if they had terminated fatally, would have been diagnosed as congenital obliteration of the duct, and others in which death probably resulted from some acute cause, as catarrhal inflammation, totally closing a congenitally narrowed but not obliterated passage. The prognosis, if the obliteration is complete and organic, is absolutely bad, and treatment can be only palliative.

Dr. La Roque reported on his findings at the autopsy on the case described, and several members added remarks which tended. to indicate that when biliary cirrhosis is found in conjunction with the stenosis the latter is the primary condition. In reply to a question Dr. Griffith said that fever is not a symptom in obstruction.

PRIMARY RIGHT DORSAL SCOLIOSIS IN INFANT.-The case of a child developing lateral curvature at the age of eleven months

was reported by Dr. H. C. Carpenter. There was no history of traumatism, and the family showed that the mother had had several miscarriages and premature births. This child, however, was born at term in easy labor. An attack of enteritis at the age of six months is the only illness it ever had. It is poorly nourished and deficient in muscular development, was breast fed for six months and since then has had broth, crackers and milk and potato. There are no subjective symptoms, no pain or tenderness, no evidence of rickets.

THE DIETETIC USE OF PREDIGESTED LEGUME FLOUR.-Drs. Edsal and Miller presented a paper on this subject, with special reference to the diet of atrophic infants. Such flours have been occasionally used for some years, but the matter has not been studied. They can be used in small quantities only, and they are not easily digested unless predigested. The series of cases studied is not large, and the results therefore somewhat tentative in character, but there is evidence that the bean proteid is readily absorbed, and that it affects metabolism fully as much as milk, or even more in the case of atrophic infants. After malting the bean flour was given in a milk mixture.

Dr. Griffith explained his interest in Dr. Edsall's experiments, and commented on the value of the results which demonstrated scientifically that the proteid in question was a valuable substitute for cow's milk.

In response to inquiries Dr. Edsall said that the experiments had not been tried on acute cases, although a number of the babies were just recovering from such. He thought that this diet enables the proteid to be increased in cases where such an increase by means of milk was not well borne, whereas the amount of milk could be adjusted to the individual case and thus guard against scurvy and similar nutritional disorders. Temporarily, also, the food could be used exclusively, since it furnished sufficient nitrogen. He had so used it in one desperate case, with success. Apparently it is easy of digestion.

NEW YORK ACADEMY OF MEDICINE.

SECTION OF ORTHOPEDIC SURGERY.

Meeting of March 17, 1905.

DR. HOMER GIBNEY, Chairman, in the Chair.

Dr. Whitman presented the following cases:-The first patient, a girl eleven years of age, illustrated the practical cure of equino-valgus deformity, caused by paralysis of the tibialis anticus muscle. This operation, which he had described before on several occasions, was conducted as follows: The tendon of the longus hallucis was divided, drawn through a hole bored in the navicular, looped over and sewed to itself and to the shortened tendon of the tibialis anticus, at a sufficient tension to hold the foot in slight dorsal flexion. Arthrodesis was then made between the head of the astragalus and the navicular and the two bones were sewed to one another with strong silk. The foot was then placed in an attitude of moderate varus and a plaster bandage applied. Soon after, the patient was encouraged to walk about, the plaster apparatus being retained for about three months in order to impress the new attitude upon the foot. This operation was, as in this instance, as a rule so effective that no apparatus was required.

It might be noted that the accessory tendon of the great toe was sufficient to hold it in proper position.

CASE 2.-This patient, a boy of six years of age, illustrated the effect of the Phelps' open incision in correcting club foot. He had performed a number of these operations recently in a type of cases familiar in hospital practice in which, because of neglect of after treatment, a certain degree of varus presisted. He thought no operation was as effective as this in assuring a permanent result in cases of this class.

CASE 3. This patient, a girl sixteen years of age, came to the hospital from Porto Rico. She presented a congenital club foot that had never been treated, and yet the deformity had been completely over-corrected by forcible manipulation without dividing a tendon even. The case was presented to contrast it with the preceding, as an illustration of the fact that the resistance of congenital deformities of this class by no means corresponds to the age of the patient. It was his custom in the treatment of club foot in youth, and adult age, whenever possible, to divide the operative treatment into several sittings, forcible correction always preceding more radical procedures. In this case the correction was easily accomplished in three operations.

CASE 4. EXCISION OF THE ANKLE FOR TUBERCULOUS DISEASE. -The patient, a woman twenty-five years of age, was admitted to the Hospital for Ruptured and Crippled last summer. presented advanced tuberculous disease of the ankle of three years' duration. On investigation the disease was apparently confined to the astragalo-tibial joint. The astragalus was removed and in order to eradicate the disease of the tibia it was necessary to open its medulary cavity. It would be noted that the result was not only a cure of the disease, but free motion had been restored. The ankle joint was most favorably constructed for radical treatment since, as in this instance one might not only remove the disease, but restore function. Another point was of interest in view of the question of plugging cavities in bone with iodoform filling, that although this might have been tolerated the patient's condition could hardly have been improved by such treat

ment.

CASE 5. TENDON TRANSPLANTATION FOR SPASTIC HEMIPLEGIA. This patient, a girl eight years of age, presented on admission to the hospital the ordinary equino-varus deformity accompanying hemiplegia. The contractions having been overcome, the tendon of the tibialis anticus with the lower portion of the muscular substance was divided into equal parts, and the outer half was attached to the cuboid bone. The foot was fixed in the over-corrected position by a plaster of Paris bandage for several months and the original deformity appears to have been overcome. In cases of this class it must be borne in mind that the operation simply restores in some degree the balance of the foot, but that cure can only be assured by constant supervision.

TORTICOLLIS.-Dr. Homer Gibney showed a case of torticollis. The boy was admitted last November, Dr. Gibney's service. He held his head inclined to the right, chin pointing over right shoulder-a compensating lateral dorsal curvature. Tendons of the

sternocleido mastoid were divided subcutaneously, after which a jacket and jury mast were applied. The jacket was continued until within the past week, when it was removed. There is no limitation of motion, no scar, spine quite straight and deformity entirely overcome.

OSTEITIS. Dr. Myers presented a case of injury to the cervical vertebrae, with symptoms of osteitis. Probably fracture of the second cervical vertebra. Cured with perfect motion in five and a half months.

M. P., boy four years of age. October 1, 1904, fell out of bed, turning a somersault. His two brothers fell on his neck. When his mother picked him up he seemed to have no power in the muscles of his neck, his head falling from side to side. He was put to bed; no other treatment.

October 22, 1904, first seen by Dr. Myers at St. Luke's Hospital. Head was held a little flexed, not rotated to either side