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One class of them are cases in which one eye has been lost, through an iridectomy, or more frequently, because the patient has neglected any effcient treatment until it was too late. Now in that class of cases it is a very serious thing to do a capital operation on the only remaining eye. Sympathectomy, done at a distance from the eyeball, threatens no danger whatever to the eyeball itself. Nothing can be lost by it; and on that account it is an operation that probably can be done earlier than iridectomy can be done; and the important point is to operate for glaucoma early.

DR. FREEMAN-I operated upon one case of glaucoma for Dr. D. H. Coover of Denver. Whether it was an unfavorable case or not Dr. Jackson can say, because I think he examined it. For a short time after the operation there was improvement, the tension decreased and the vision increased. After that the case relapsed to its former condition.

OPERATION FOR CHRONIC OSTEOMYELITIS IN A PATIENT WITH A CONSTITUTIONAL

DYSCRASIA.*

By E. S. WRIGHT, M D.,

Salt Lake City, Utah.

It is quite natural to seek information when a patient of ours dies under our care and quite natural to impart information when they get well. I find myself in the former predicament upon this occasion and would like to reaffirm what I have often said before: That some of the very best lessons we could learn are the unreported dead.

In reviewing the literature of this disease, I have not been able to find a satisfactory article covering the case I desire to report hence feel like submitting the case for your consideration. I have not selected this case to show my prowess in operating, as

*Read before the Rocky Mountain Interstate Medical Society, Ceyenne, Wyo., Sept 9th, 1902.

it would be a poor one, from the fact that my patient died, but, as an instructive case, presenting some rather extraordinary symptoms following an operation that I have not, heretofore, considered so grave as many other operations that are constantly being performed.

Osteomyelitis, uncomplicated, is a disease from which, ordinarily, we can get great satisfaction from an operation. It is constantly receiving attention from surgeons without even the serious thoughts and feelings incident to, say, an appendicitis operation, not nearly so extensive. Much has been said and written upon this subject, and since tuberculous disease of the bones has become better known, this question has become almost entirely absorbed by it, so that a case coming to the observation of a surgeon, with a disturbance in the bony frame-work, especially in the extremities, is looked upon as more than likely of tubercular origin. It is probable, imbued as we are with a widely extended territory covered by this disease, we may, at times, take it for granted that nearly all such cases have their origin in this form of trouble. In hastily drawing such conclusions, we may make mistakes. The subject of bone diseases is so voluminous that I think even good men, unless they have had occasion to look it up, are not generally posted pertaining to the more technical learning in regard to such diseases. Be that as it may, I found myself somewhat at sea to cope with the unexpected symptoms presented in the case I now report.

Case: Adam W., aged twelve years, was referred to us by Dr. C. L. Olsen of Brigham City, and came under my care. The history of his case was that, since infancy, he had a swelling on the outer part of his right leg, just above the external malleolus, and the mother's answers in regard to the family history, are given by her as follows:

1. There never was any member of the "W." family that I know of, afflicted with consumption.

2. Adam's father died of brain fever and spinal meningitis. 3. No, he never did bleed very much.

4. I have had those moles from infancy.

5. I think it was four days after he was born that we noticed the small lumps, and then there were seven, about as large as a small marble. After we had his leg doctored, it formed in one

large mass. The spots upon his body never appeared until he was five years old.

6. I never do bleed very much in any way.

A careful examination of the patient showed a swelling, as above stated, that proved to be quite sensitive upon pressure, and was located on the outer aspect of the leg. The bone seemed to be more sensitive than the tumor itself, which suggested to us a trouble allied to a cold abscess, which conclusions was changed later to one that it was of an angiomatous nature. There were petechiae over the body; in fact, minute venous hemorrhages beginning small like a pin head, and enlarging slowly into a venous tumor. They could be found on any part of the body, the soles of the feet and elsewhere. One as large as an almond, at the junction of the foot and leg on the anterior aspect of the left leg, was removed at the time of the operation.

The child seemed to be a good subject for operation, though he had an evening temperature, which perhaps, had troubled him for some little time. Arrangements were made to attend to the operation according to the usual method and care observed for a clean piece of work. In cutting down on the growth, great care was taken, and it was not opened directly, but, from the evidences in the case, we concluded to find out the condition of the bone adjoining the tumor. We were surprised to find the thickness we did of the skin, and especially the periosteum, which was thickened to five or six times the normal condition, and suggested to us the long standing of the inflammation from which he had suffered. In cutting down upon the bone, we found it honeycombed, and it would crumble between your fingers very readily. This condition of the bone extended from the site of the tumor and a little above, to the lower head of the tibia, requiring a liberal scooping of the head of the tibia, but, as far as we determined, it did not involve the joint. A feature of the work, after removing the bone, was the difficulty we experienced in controlling the bleeding from the periosteum that had been left from the side of the tumor, to perfect the operation. We finally succeeded in tieing up most of the vessels, by packing, the ordinary pressure from bandaging, and controlled the bleeding quite satisfactorily, though there was some oozing, as is common from such wounds.

The patient took the anaesthetic, chloroform, well, and rallied promptly from the operation. The temperature chart, here

with presented, shows a very active and unusual reaction following the operation, and, as will be noticed, for almost a week, the temperature persisted in remaining around 105 degrees, and not infrequently, recording in the axilla a temperature of 106 3-5 degrees. The conduct of the wound, during all this violent reaction, was such as to show no evidence whatever of the absorption of poisonous products, as it remained free from any marked swelling or redness, the ordinary symptoms of inflammation. The drainage was good, though the tendency to bleed was a little pronounced. There was at no time, any evidence whatever of a local seat of pus formation. The patient suffered considerable pain, though had a good appetite during the illness after the operation, lasting two weeks. The treatment, including the antipyretics, cold sponging, frequent change of dressing, under special precautions from the first, hypodermoclysis of salt solution, antistreptococcic serum, subsequent incisions to insure no possible seat of infection, were all of no avail. We seriously contemplated removing the leg by amputation, but the temperature at this stage was so high, we felt it offered little or no hope, hence abandoned the idea. The patient was, at times, slightly delirious, though generally, the nervous system remained intact.

Before the patient came to us, we were informed that another doctor had inserted a hypodermic needle, with a view to determine the character of the contents of the swelling, but obtained nothing but blood. Our conclusions were, after noting the peculiar conditions elsewhere in the body, that we had to deal with some form of blood tumor, and acted accordingly in our operation. The bleeding from bone and surrounding tissues was marked and persistent, as the least irritation in dressing the wound would cause a general oozing near the surrounding parts. During the progress of his sickness, the patient suffered one or two chills, though they were not as severe as might be expected from an infection. The interesting question for consideration is, why such symptoms followed a clean operation, that proved to be clean to the end, with good drainage, etc., etc. Could it come from the profound anaemia which took hold of him at once, notwithstanding he had a good appetite, and his system reacted well to treatment, directed to the organs of excretion? The little blood tumor on the other limb remained entirely inactive, and no healing what

ever followed its removal. The patient from the outset presented intractable symptoms that would not yield to any kind of treatment, and appeared to be in a constitutional condition that all he needed was the operation, to set up the reaction, that went through him like a fire in a cane brake.

A CASE OF DELAYED ERUPTION OF SYPHILIS,
COMING ON FOLLOWING ABORTION AND
RESEMBLING SMALL POX.

By GEO. A. MOLEEN, Ph.D., M.D.,
Denver, Colo.

Mrs. E., female aged 37; occupation, palmist. Born in Illinois. In Colorado since June, 1902, when she came on account of bronchitis. Family history: Mother died of dysentery, father of old age (83) and negative otherwise.

Husband had been to Hot Springs, Ark., for treatment of syphilis before marriage, upon learning of which she was separated from him four years ago.

Previous history: Measles, scarlet fever and whooping cough, without sequelae, she had of the diseases of childhood and has enjoyed good health since, with the exception of malarial attacks, and the bronchitis for which she came West.

Was successfully vaccinated as a child, but not since. The last attack of malaria occurred in 1885 in Kansas City.

In 1898 was in hospital for menorrhagia, but denies curettement or operation of any kind.

Her menstruation is regular but has some leucorrhoea at times. Has given birth to no children though she has induced several abortions, the last one about four months ago, from which she did not recover as rapidly, that is, she "did not feel right" for some time.

About eighteen months to two years ago patient had a sore on her under lip, which she insists was a "cold sore," though it lasted longer than usual, and describes it as a hard swollen sore, and which finally disappeared after the use of olive oil.

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