BUFFALO

Medical and Surgical Journal.

VOL. V.

JANUARY, 1866.

No. 6.

ART. I-Transactions of the Medical Society of the County of Kings.

Specimens and Cases.

MONTHLY MEETING, JULY, 1865.

Tuberculous Disease of the Foot.

DR. STILES presented a diseased foot, removed from a woman, aged twenty years, and an inmate of the Kings County Hospital for four months, having been for one year previously, under the care of a physician in Brooklyn. Shortly after admission an intense inflammation set in, in the affected part; this, however, gradually subsided, but not until sinuses had formed, which communicated with cavities in the foot. The subsequent treatment was directed principally to the general system, but the patient became weaker, and amputation was decided upon. On examining the amputated foot, found a tuberculous disease of the astragalus, a disorder that occurs but rarely in that bone. In the anterior portion of the astragalus and os calcis was a cavity lined by false membrane, and connecting with this were numerous sinuses all over the foot. In this case had a probe been introduced, no dead bone could have been felt, owing to the presence of this false membrane. There was no disease of the tibia. The suppuration was so profuse that the patient would have died had not amputation been resorted to. Syme's operation was talked of in this instance, but it was thought inapplicable.

DR. ENOS briefly referred to the case, and thought that Syme's operation might have been successful.

DR. WM. OTTERSON remarked, that in civil life Peregoff's operation, in these cases, might be resorted to with success; but among soldiers, whose constitutions were more or less feeble, and their vitality impaired, it rarely succeeded. In the present instance, the patient being so weak, and Syme's operation being so low VOL. 5, NO. 6-29.

down, he thought it would not be successful; the parts would not heal.

DR. MINOR thought that Syme's operation might have been first resorted to, and then if the tissues were found diseased, the operation might be performed higher up. If success attended the first operation, the patient would have a larger stump, and if the peroneal artery were left long, it would prevent a great deal of sloughing.

Rupture of the Heart.

DR. SPEIR presented a specimen of rupture of the heart. On opening the pericardium a large clot was found enveloping the heart, and on removing this, a little blood spirted out of a small opening, which communicated with the left ventricle. The heart was hypertrophied and fatty, and at the point of rupture the wall was very thin, and exceedingly fatty. A few of the columnæ were ruptured, and there was calcification of the coronary artery. Atheromatous deposits were also found.

DR. ENOS stated that he had been in the habit, for some time back, of tapping this man for hydrocele, in his office. His attention had never been called to any trouble about the heart. About a week ago he was sent for in haste, but on arrival found him dead. On enquiry found that the man had come home that evening, com'plaining of feeling a little chilly, and soon afterwards fell down and expired. He had been lifting a little that day, and complained of feeling tired.

The question here recurs, did the lifting cause this small rupture? He thought it strange that this man should have had such an amount of disease of the heart, and still not complain of it.

DR. STILES referred to a similar case reported by Cruvellier, where there was a large mass of fat on the heart, giving it a yellowish appearance.

MONTHLY MEETING, OCTOBER, 1865.

Valvular Disease of the Heart.

The

DR. STILES presented a specimen of endocardial trouble. patient had been suffering for six months from disease of the heart,

and when admitted into the Kings County Hospital, the dyspnœa was very distressing. There was slight swelling of the lower extremities. There was dulness on percussion for the space of three inches above the nipple, and auscultation revealed the double bellows murmur, but no rasping sound. The murmur was very slight with the first sound of the heart, but very distinct with the second. The man had not had any prior rheumatism. He died suddenly on the 14th instant. On post mortem found a perforation of one of the semilunar valves; to this cause can be attributed the bellows murmur. One of the semilunar valves was enlarged, the others small.

Typhoid Fever.

DR. STILES also related the following case: About three weeks ago a man was admitted into the Kings County Hospital with typhoid fever, and had so far recovered as to be able to go about the ward. In returning from the water closet last night he fell down, and soon afterwards expired. On post mortem found a profuse ulceration of the colon in the right hypochondrium, and a small perforation of the intestine. There was a large amount of yellow fæcal matter in the peritoneal cavity, and the abdomen was tympanitic. The ulceration in this case had not been confined to Peyer's plates. Between the ulcerations the membrane was greatly inflamed.

DR. HUTCHISON presented a specimen of senile gangrene of the foot and leg, from calcification of the arteries. (Notes by Robert Newman, M. D.)

Joseph Stephenson, aged 64, a native of Ireland, for 24 years a resident of this country, was admitted to the Long Island College Hospital, Brooklyn, March 10, 1864, with dry gangrene of the left lower extremity. He stated that he had always been healthy, but for the past four years very intemperate. On the 20th of February ult., while returning home intoxicated, he fell several times, once hurting himself so severely that both he and those who came to his assistance supposed the leg to be broken. On the following day he noticed a slight contusion on the left leg an inch and a half above the external malleolus, and felt a numbness and coldness in that foot. When admitted to the hospital March 10th, the entire

foot and a small portion of the leg were black, dry and shriveled, resembling closely the appearance presented by a dried mummy. Its condition at that time is well shown in the specimen. The gangrene extended somewhat higher upon the anterior than upon the posterior portion of the leg, and formed a distinct line of demarcation. The leg was enveloped in cotton batting, supported by a bandage. He was given beef-tea and the most nourishing food, ale and 3 ij of whisky per diem with opiate.

On the 18th the line of demarcation being completely and distinctly defined, and the general health of the patient not being likely to improve, it was decided on consultation to amputate the leg. This was done by Dr. J. C. Hutchison, Professor of Surgery in the presence of the medical class. The leg was amputated at the point of election, four inches below the knee, by the flap operation. There was less than an ounce of blood lost, the only hæmorrhage being from the cutaneous vessels. The large arteries were in a state of calcification, and so completely blocked with lymph as not to bleed. This state of the arteries gives sufficient explanation as to the cause of the gangrene. Though scarcely necessary, a ligature was applied to the anterior tibial artery. The flaps were joined together by silk sutures and adhesive strips. The flaps and limb were cold at the close of the operation. Hot sand bags were placed about it until the limb regained its normal temperature. March 28, gangrene set in at two points on the anterior flap. Pulse 100 and feeble; patient taking food and stimulants freely. On the 30th the gangrenous portions of the flap began to slough, laying bare the tibia. The wound continued to slough for ten days following. The prostration gradually increasing until the afternoon of April 13, when he died, twenty days having elapsed since the operation.

From a post-mortem examination held the following morning, it appeared that the gangrenous slough had extended nearly to the knee. The femoral artery and sheath were surrounded by masses of fat intermingled with calcareous deposit. When first removed it had the appearance of being badly injected with plaster of paris, and was, as is shown by the specimen, in a state of calcification.

In the specimen the arteries of the leg have been dissected from the point of amputation nearly to the gangrenous portion, and

present the appearance of mere bony tubes or cords. The anterior tibial was completely calcified and occluded, and the posterior tibial nearly so. The peroneal was much enlarged, was also diseased, but the most perfect. The left ventricle of the heart was slightly hypertrophied, the aortic semilunar valves thickened, one segment gaping widely. Atherometous, and calcaneous deposits were found in two valves; the aorta was normal. There was no lesion in the other organs.

It is evident that the gangrene was caused in this case by the obstructed condition of the trunks of the vessels, which existed for some time before the death of the part took place. The existing cause was probably the slight inflammation produced by the contusion before referred to, which disturbed the balance of the circulation in the already weakened part to so great an extent that gangrene ensued.

Dysentery.

In

DR. STILES presented three specimens, selected from fifteen cases of dysenteric affection. In general he found that the ulcerations had destroyed the mucous membrane down to the cellular tissue. Sometimes the membrane was perforated like a sieve; at other times it looked as if shot were scattered under the membrane. one case there was no ulceration, but the folds of the membrane were sphacelated. When these folds slough, the case terminates fatally, and in his opinion a few hours is sufficient to convert a curable into an incurable case. The thickness is in the muscular coat, and in the cellular tissue, and not alone in the sub-mucous cellular tissue. There was no lack of secretion of bile, but the excretion of it was deficient.

DR. REESE inquired how it was that death took place so suddenly from the perforation of the bowel in the case of typhoid fever?

DR. BELL inquired why sphacelus of the folds of the mucous membrane should necessarily make a case incurable? He thought there might be very extensive ulceration of the mucous membrane, and possibly even of the muscular fibres of the intestine, and recovery still take place.

Dr. Enos agreed with Dr. Bell in regard to recoveries from extensive ulcerations of the intestines, and cited a case in whic