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“About the 18th of September, 1884, I was invited by Dr. E. E. Gouchee of McMinnville, Or., to accompany him to Amity, a town seven miles distant, whither he had been called to see W'illie Witherel, a child about eighteen months of age, who was accidentally thrown under the cars and had both legs passed over; one about the junction of the lower third with the upper two thirds of the femur, the other, the wheel passed over in an oblique direction from the upper part of the poplitcal space to the attachment of the ligamentum patelle, crushing both condyles of the femur. Reaction being complete, we decided to operate at once.
On one limb we made an antero-posterior flap by transfixion, on the other we made a grand modification of every operation extant. Being desirous to save all the tissue we could, we made something of a circular operation with the foregoing modification. After the flaps were made the great sciatic nerve was sought for and cut sufficiently short to prevent pressure upon it by the cicatrix. I asked permission of Dr. G. to use my artery-occluder instead of the oldfashioned ligature. To this he gave consent, and the arteries were secured with the instrument, there being in one stump two vessels which required its use, and in the other but one, and that just above where the femoral becomes the popliteal artery.
We uscd dry sulphate of quinia as an antiseptic, the wound bedusted full of the same and closed. A drainage-tube was then introduced, and an ordinary compress applied. One bruised to a small portion of burned flesh being left in the stump.
I think the case was discharged three weeks after the accident. The little fellow is now alive and doing well.
This being a double femoral amputation, and the first case so far as I am advised, where the arteries were secured without a ligature, makes the case truly interesting.
I do not know just what stress should be laid on cutting the nerve above the cicatrix, but there is nothing to be feared from so doing, and perhaps there is much gained.
J. P. TURNEY, M.D."
The Doctor also furnishes the following notes of a demonstration on a dog, made by him before the Yamhill County (Oregon) Medical Society:
“I laid the femoral artery bare in its course through Scarpa's triangle to the extent of about one and one-half inches, divided the artery at the lower portion of the wound, and tied both ends. After those present had seen all they wished the wound was closed, without the usual antiseptic precautions; the dog was kept tied for three days, and then allowed his liberty. I saw the dog this spring (six months later) in as good condition as before the operation."
That the inventor fully appreciates its value and importance is evidenced by the following quotation from a personal letter:
“I think the instrument renders possible operations which could not be done without it. There is less danger from septic poisons; no danger of secondary hemorrhage; no delay for the sloughing of ligatures, and many other things which will suggest themselves to you. I think it will prove of great value in abdominal surgery.'
Dr. Turney desires the world to have the benefits of his invention, devoid of that unprofessional incumbrance, a patent, being satisfied with the approbation of the profession, and has requested the writer to describe and designate it by a suitable name. In honor of its inventor I have selected as an appropriate name The Turney Artery Occluder.
By Philip ZENNER, A.M.,M.D., Cincinnati
College of Ohio.
The membranes of the brain consist of the dura mater and the pia mater. Inflammations of the dura mater, excepting those of traumatic origin, are rare and of little interest to the general practioner; we will, therefore, pass them by. Inflammations of the pia mater, on the other hand, are the most common acute endocranial affections, and, therefore, of great importance in practice.
We will distinguish but two forms of meningitis, the tubercular and the purulent, under which most cases of the disease may be classified. Tubercular meningitis is the most common. It occurs most frequently in young children, where the disease is limited mainly to the basilar portion of the brain. It occurs also, though more rarely, in adults, where the membranes covering the convexity are also commonly involved, producing a different clinical picture.
Purulent meningitis includes that produced by injuries of the head, disease of the middle car, etc., and cerebro-spinal meningitis. The latter prevails chiefly as an epidemic, though it sometimes occurs sporadically. In it the inflammation is usually greatest in the basilar portions of the brain.
he most common changes found in the brain in these cases are, general oedema of the brain or effusion into the ventricles, and circumscribed areas of softening in parts of the cortex or the basal ganglia. Morbid conditions are also found in the cerebral nerves, inflammation, atrophy from pressure, etc.
The symptoms of meningitis depend on the extent, locality and intensity of the disease. For that reason we cannot make a sharp distinction between the symptoms of purulent and those of tubercular meningitis. For practical purposes it will be most advantageous to describe some of the most common clinical pictures as they occur, which, depending on the factors mentioned, extent, locality, intensity, may apply to either purulent or tubercular meningitis.
We will first take the most common clinical picture. It applies to most cases of tubercular meningitis of infancy, and to many cases of cerebro-spinal meningitis. In the former the duration is usually from one to two weeks. In the latter, especially at the beginning of an epidemic, when the disease occurs in its most malignant form, the attack is often so sudden and severe as to simulate an apoplectic attack, but in the majority of cases the following description applies :
The patient appears at first to suffer little in general health. There is loss of appetite, constipation, malaise and pallor. He is then unexpectdly seized with a convulsion followed by coma, and the coma, or at least a condition of somnolency, continues throughout the course of the disease. But even though unconscious, his moaning, the movement of the hand toward the head, indicates something of his physical suffering.
The further symptoms may be divided into :
(11) Irritative symptoms : grinding of the teeth, nystagmus, (or oscillations of the eyeball from side to side) and convulsions, which often occur in large numbers.
(6) Disturbance of the vegetative functions: vomiting, constipa tion, irregular breathing, and changes in the pulse. The latter is of special importance. Usually, even at an early stage of the discase, the pulse is slower than normal and is in great contrast with the state of bodily temperature. For meningitis is essentially a febrile disease, the temperature is more or less elevated. A slow pulse with elevated temperature should, therefore, always arouse the suspicion of meningitis. Toward the end of the disease, when the fatal termination is near, the pulse becomes very rapid.
(c) Symptoms on the part of the cranial nerves: contraction or dilatation of the pupil, in the later stages paralysis of the external muscles of the eye, and a feeling of stiffness and rigid contraction of the muscles of the back of the neck, causing the head to be drawn backward, especially observable in cerebro-spinal meningitis, but also found in other forms of the disease.
Of these only the subjective symptoms, pain and restlessness, are to be directly attributed to the affeetion of the meninges, for the latter are doubtless the most sensitive of the cerebral structures. The unconsciousness is due to increased pressure within the cranial cavity, caused either by oedema of the brain, or, more frequently, by large effusions into the ventricles. To this increased pressure, or to the extension of inflammation along the sheath of the nerves, is to be attributed another symptom which is often of much value in diagnosis, and which is only detected in examining the retinae of the eyes with the ophthalmoscope, the so-called choked disk. The outines of the optic disks are not so sharply detined as in health, the surface looks hazy and is somewhat elevated, and the vessels, arteries and veins, are altered in size. This symptom is often of great value, for it may be found when the diagnosis is otherwise very obscure. But, unfortunately, it is often of little avail in practice, as special skill is necessary for its detection.
The convulsions are due to increased brain pressure, or to irritation of certain parts of the brain, perhaps generally the grey matter covering certain convolutions,
As before mentioned, the pathological changes in these instances are chiefly in the basilar portions of the brain, and most of the symptoms are due to local changes in this part. Thus, the drawing back of the head, paralysis of the ocular muscles, vomiting, constipation, irregularity of breathing, changes in the pulse, are directly due to involvement of the medulla oblongata or the nerve roots emanating from it.
There is frequently, in addition to the above symptoms, aphasia, from localized lesions of the third frontal convolution or its neighborhood, and sometimes hemiplegia from softening of the corpus striatum, caused by changes in its nutrient vessels.
The clinical picture we have just given is that of most cases of purulent meningitis and tubercular meningitis in children. But, occasionally, the latter does not run so rapid a course, and presents a somewhat different clinical picture. The disease comes on insidiously, with changes in the child's disposition, irritability, wilfulness, being easily frightened, headache, pallor, and failure of general health.
At the same time there may be some fever, and irregularity of the pulse, and ophthalmoscopic examination may reveal the choked disk. An epileptic attack now ushers in the appearance of a grave disease, and we may have again the symptoms already detailed. In those more chronic cases, sometimes of months' duration, a few symptoms become prominent, which are either absent or less noticeable in the acute cases. Among these are obstinate constipation with a very retracted abdomon, hyperæsthesia both deep and superficial especially over calves, neck and back, and what the French have termed the cri hydreacephalique, the frequent starting from a condition of sleep with a sudden shrill cry.
Tubercular meningitis in adults often presents a very different clinical picture, we often find a condition which greatly resembles delirium tremens, in fact resembles it so closely that often only a post-mortem examination will reveal the two conditions. There is the same restlessness and sleeplessness, the same hallucinations and confusion of ideas. And even the intercurrent convulsive seizures might also be found in cases of delirium tremens.