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of the hip joint, states that the age of limitation is about the seventh or eighth year. While he can bring about the reduction and reposition of the extremity in a case much older, the result is not satisfactory. He further states that up to the age of six or seven years, any physician who will follow his instructions can get good results from an operation on congenital dislocation of the hip. If the case be too old, the amount of traumatism necessary to bring about a reposition is liable to be followed by a paralysis from which a perfect recovery is doubtful.
Resection of the hip joint for hip disease is followed by good results in childhood, while if a resection of the hip be made in an adult there is grave doubt about his regaining any use of the extremity. Operations for the correction of ankylosed joints, where the ankylosis is the result of a tubercular joint disease, are followed by better results in children than in the adult. Resection of joints or bones in children are followed by a surprising usefulness of an extremity, whereas, in similar conditions in the adult the extremity had better be amputated.
For club foot, the earlier the operation is performed, the more easily can the deformity be corrected and the more perfect usefulness be the result of the operation. Club foot in the adult can be corrected, but the tissues are so strong and unyielding that they must be divided, and consequently a greater amount of traumatism is done in the reduction of the deformity. The adult does not recover so quickly or satisfactorily from traumatic injuries involving the bones and joints of the foot.
In children, cranial operations, abdominal operations, and operations involving vital organs, if carefully executed, are followed by results quite as good if not better than the same surgical procedure in the adult.
Surgical proficiency acquired through experience in operating on adults as well as on children, gives a degree of confidence and familiarity with the surgical technique, whereas, the surgical dexterity counts for much in the economy of time and manipulation during the period of the operation. It has been proven that infants stand the anesthetic when properly administered quite as well as the older subjects. Operations on children for the cure of lesions, the correction of deformities, or the removal of a neoplasm should not be put off, but should be resorted to at an early age, and generally speaking, the earlier the better.
Not long since, I received a letter from a physician stating that in his practice he had an infant suffering with a large inguinal hernia. He stated that he was unable to retain the hernia with any device that he could get and wished to know if an operation could be performed on an infant that was about four weeks old. The patient was a male and the first child. It was unusually small and delicate at birth and was a bottle-fed baby. It had been sick since birth and its appearance showed plainly a defective nutrition. The patient was brought to the hospital and prepared for an operation for the radical cure of hernia. The operation was performed and the same general surgical technique carried out that is usual in a herniotomy in the adult. The incision over the inguinal canal was only about one inch long, and this was a long incision, as compared to the size of the patient. No difficulty was experienced in separating the sac from the tissues of the cord and opening the same. When the sac was opened and its contents examined, an anomalous condition was found that sometimes occurs in congenital hernia. The lower portion of the cæcum, together with the vermiform appendix, protruded into the scrotum. The appendix and mesocolon were adherent to the tunics, cord and testicle. The tip end of the appendix was down in the lower part of the scrotum. These adhesions were separated and the vermiform appendix removed, and the cæcum returned to the abdominal cavity. No difficulty was experienced in picking up the transversalis fascia and uniting it to the shelving edge of Poupart's ligament by suture. The cord was replaced in the canal and the aponeurosis of the external oblique sutured in the usual manner. The external wound was closed with silkworm gut sutures and the wound sealed with collodion dressings.
F. J. HOLMES, M. D., SAUGATUCK, MICH.
A knowledge of this subject is of especial importance to physicians, especially since Lorenz' visit to the United States has aroused a new interest in disorders of the hip.
Every practical surgeon has met with several varieties of "chronic rheumatic arthritis," or of morbus coxæ senilis, and has examined morbid specimens in pathological museums. Those specimens which illustrated the morbus coxarius of childhood were exceedingly instructive, yet not more so than the preparations which exhibited the effects of chronic inflammation of the coxofemoral articulation. The specimens arranged to display the effects of rheumatoid arthritis present two quite distinct varieties: one displayed hypertrophy of the head and neck of the femur; and the other demonstrated marked atrophy of the cervix femoris. Medical men with limited opportunities for necroptic observations might take the cases of hypertrophy for evidence of intra-capsular fracture with osseous union; and the cases of atrophy for proof of intracapsular fracture with fibrous or non-union. So pronounced were the demonstrations that I viewed with interest the preparations of other hospitals of Europe, and found that we were not always sure when examining a living subject, whether fracture of the neck of the femur existed, or we had a case of rheumatic arthritis under inspection. If an injury of the hip had been sustained, and the patient walked afterwards, or within a few days, the logical sequence is that fracture had not been sustained; for a patient cannot walk with a recent fracture of the cervix femoris.
What, then, may be the nature of the injury or defect if the limb is shortened, the foot everted, and there be osseous outgrowths in the femur near the acetabular brim? Dissections show that under chronic arthritis of the hip-joint the neck of the femur may be so far atrophied-removed by absorption—that no cervix remains. The head of the bone is usually left, and the trocanter major shows nodulated masses of new bone springing from it as if to repair a damage to the parts bearing ledges of osseous outgrowth. Sometimes in the vicinity of trocanters, under inflammatory action (periostitis), there will be developed osteophytes, or spurs of bone, which may be quite spiculated and rough like stalactites.
In elderly subjects, who exhibit more or less locomotor ataxia and the scaly skin peculiar to enfeebled constitutions, the effect of rheumatic arthritis is apt to be atrophic; and because the peculiar defects were first depicted by that eminent French surgeon, Charcot, the atrophic variety of arthritis is denominated "Charcot's disease.”
In this kind of rheumatic hip, when the neck of the femur is absorbed, small plates of bone are often found in the substance of the modified capsular ligament; and the upper extremity of the shaft of the femur will be as hollow as a log, or lightened by excess of cancellation. The bone is more porous or spongy than natural.
Charcot regarded senile arthritis of a rheumatic and gouty nature as neurotic, something like spinal paralysis existing as a cause of the joint disease. In atrophic arthritis there is increase of passive motion, the affected joints moving like a flail, and the patient is not able to move the diseased limbs with precision. These features are both pronounced and diagnostic, though often overlooked. The atrophic state, after it has set in, develops with considerable rapidity, a few weeks being sufficient to remove the neck of the femur.
Dr. R. Adams, in his illustrated work on diseases of the hipjoint, relates some interesting cases bearing on rheumatic arthritis. One is as follows: "Charles Matthews, the celebrated comedian, about ten years before his death, was thrown from his gig while descending Ludgate Hill. He got up and walked immediately after the accident, but continued lame as long as he lived. He consulted the most eminent surgeons of London, but they were unable to determine whether fracture had been the cause of the lameness, but they kept the distinguished patient lying on a sofa for nearly twelve months. The injured limb was shortened, the foot everted, the thigh wasted, and owing to a constant inclination of the body forward, a lateral curvature of the spine took place. After death, the actetabulum and femur was secured for examination. There had been no fracture, but such changes had occurred in the neck of the thigh-bone as to lead to the suspicion that there had been intra-capsular fracture.” Dr. Adams exhibited the specimens to the British Medical Association, and demonstrated to the satisfaction of all that Mr. Matthews had suffered from what passes as morbus coxæ senilis. Even Mr. Snow Harris, who had entertained the view that fracture was the cause of the atrophic changes, became a convert to the theory of rheumatic arthritis.
The subject of senile rheumatism of the coxo-femoral articulation is ably discussed by Mr. Edward Canton in his chapter On Shortening of the Leg from Bruise of the Hip. Significant points are illustrated by drawing from specimens in the museum of Charing-Cross Hospital. And, what is important, clinical histories of each case attend the specimens. In some “mixed” cases there is exhibited hypertrophy of the head of the femur, atrophy of the neck, and osteophytes about the trocanters. While the degenerative processes are going on, there is evidence that reparative action is developing osseous outgrowth in places, as if to repair an injury.
In "Charcot's disease"-locomotor ataxia—the vital degeneration is so radical and pronounced that no course of treatment seems potent to check the downward course. There is probably some lesion of the spinal cord, which generally leads to fatal paralysis. The muscles of the leg become flabby through waste and fatty degeneration, and the integument of the limb exhibits an inelastic and scaly condition. The patient gradually loses the ability to poise
himself on crutches, and at length becomes permanently bedfast. The confined state contributes not a little to hasten the impending dissolution.
J. F. BARTON, M. D., El Paso, TEXAS.
Dermatalgia, or neuralgia of the skin, is a disease so rare, and so little has been written on the subject by authors, that I think a reference to it, with some cases illustrative, may be of some benefit, even if worthy but to provoke discussion.
Dermatalgia is not classed among the neuralgias but with the skin-diseases; and it is not therefore necessary to give a history of the constitutional effects of neuralgia, except to say that one of the cases mentioned below was very much affected constitutionally and received active treatment in that direction, besides the external use of cocaine, to which your attention is principally directed in this article.
Dermatalgia is usually confined to a limited portion of the skin which becomes the seat of an intense pain or burning sensation, paroxysmal in character, and often distinctly periodical. No change may exist in the appearance of the skin, but in some cases an erythematous condition will follow. Fox says that this condition is always symptomatic in character; but in one of my cases the external application of cocaine produced permanent relief, after constitutional remedies—and these directed to the nervous systemhad failed.
I. In September, 1885, I was called to see an old lady of eighty-two years, who was suffering from an intense pain over the right eve. She was in good general health and had been for many years, except that during the last seven years she had been attacked often by this pain, which usually lasted several weeks, with more or less pain each day. The treatment she had received from different medical men seemed to be only palliative, and the attack would gradually wear away. The seat of the difficulty extended from the median line of the forehead to the right, and from the eyebrows to the roots of the hair of the scalp. The severest pain was referred to a spot the size of a silver dollar, just over the outer angle of the orbit and including the eyebrow. The pain was of an intense burning character, the lightest breath of air intensifying it. During eating, the action of the muscles so increased it