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From this time he progressed favourably, so far as the head symptoms were concerned, the brain disturbance gradually subsided, and the wound healed. His temperature never was high ; on two occasions only, at night, the thermometer registered 101, but it was usually a little above the normal standard. Pain in the head was persistent, confined to the right side, and there was troublesome constipation, which required the occasional use of salines. On the 30th March, the report states that the pain in his head is less severe, he takes food well, and a more generous diet was allowed, but he seems listless, disinclined to leave his bed; he is weak, and has notably emaciated. His pulse is 96, and his temperature is normal in the morning, with a slight rise at night. The ice cap was discontinued, as was also his mixture ; he complains of cough, and expectorates freely ; has slight night sweats, but sleeps moderately well.
His chest was examined, and there was found consolidation at the apices of both lungs, with evidence of softening. On inquiry, it was ascertained that some four years ago he suffered from a severe attack of pleuro-pneumonia coming on after exposure to cold and a thorough wetting, having been upset from a boat while fishing, and at the time nearly drowned. During the attack his life was despaired of, as it was severe and persistent. There was no attempt at resolution. His physician recommended change of air, but he remained in the city Since that time he had suffered from several attacks of hæmoptysis, and the cough, with expectoration, has persisted throughout, with occasional night sweats, general symptoms of debility and steady emaciation. There is no history of phthisis in his family ; his father and mother are still alive and enjoy good health, and all his immediate relatives are healthy. A tonic was prescribed, good diet and an expectorant mixture ; and, with a view of giving him the chance of benefit of change of air, as the spring of the year had fully set in, he was advised to go to the country and live as much in the open air as possible, partaking of milk and eggs, with a moderate allowance of stimulants.
He left the Montreal General Hospital on the 27th April, and subsequently entered the Hotel Dieu Hospital, the disease of the lungs progressed steadily, and he died on the 12th August, following
As an illustration of the absence of all permanent brain disturbance, it may be mentioned that two days before his death he wrote a letter to his mother which was clear in diction, well composed and hopeful in character. He died apparently syncopal, as he had complained of feeling very weak, was more than usually languid, and passed away quietly and quite unexpectedly. Through the kindness of Dr. Angus C. Macdonell, physician to the Hotel Dieu Hospital, a post-mortem examination was secured, which adds additional interest to this unusual
Post-mortem examination made 24 hours after death :Extensive disease of both lungs was found; the upper lobes were riddled with cavities of various sizes. There was no special examination made of the other viscera, as permission alone was granted to examine the brain. On reflecting the scalp, an oval-shaped opening through the cranial wall was observed. This opening was longer vertically than transversely. It was situated above the extremity of the great wing of the sphenoid, and involved the anterior edge of the squamous portion of the temporal bone, and also the anterior inferior angle of the parietal, it was almost closed by a firm, fibrous membrane. On opening the cranium, the inner surface of the dura mater, on the right side, was of a deep yellow color. This extended to the right surface of the falx cerebri, and also to the right half of the tentorium. The brain surface was likewise stained, but was not quite so deep in color. This was evidently due to effused blood, an extensive clot which had been absorbed. Near the point of entrance of the bullet through the dura mater were found several fragments of the inner table attached to that membrane. A large fragment of the inner table remained attached firmly to the posterior margin of the opening in the bone internally, being slightly tilted forwards, and had apparently changed the course of the projectile. The bullet entered the brain substance at the posterior margin of the right inferior frontal convolution, just in front of
the angle formed by the ascending and horizontal branches of the fissure of Sylvius. It passed upwards and forwards and out through the inner and anterior margin of the middle frontal convolution, resting between the brain substance and the falx cerebri. It lay surrounded by a firm membrane, and was one quarter of an inch in front of, and on a line with the anterior extremity of the corpus callosum. From the point of entrance through the trajet of the bullet, a firm membranous canal existed, around which, and for about three-quarters of an inch in extent, the substance of the brain was softened.
[We are indebted to Dr. James Bell, Assistant House Surgeon of the Montreal General Hospital, for the above carefully prepared record of the course and position of the bullet in this interesting case.-ED.]
Reviews and Wotices of Books.
The Principle and Practice of Surgery, being a Treatise on
Surgical Diseases and Injuries.—By D. HAYES AGNEW, M.D., LL.D., Professor of Surgery in the Medical Department of the University of Pennsylvania. Profusely illustrated. In two volumes. Vol. 1, royal 8vo, pp. X., 1062. Philadelphia : J. B. Lippincott & Co. London: 16 Southampton street, Covent Garden, 1878.
This volume forms the first part of Dr. Agnew's voluminous treatise on the Principles and Practice of Surgery. The author has expressed bis views freely, based on his own experience and observation, which has not been limited, as he has had the advantage during the past quarter of a century of having under his charge surgical diseases and accidents in the hospitals of Philadelphia. Some of the enunciations here recorded are original in conception. They differ in some measure from the views and teaching of other surgical writers, still they bear the stamp or honest conviction based on careful observation. In wounds of the scalp, sutures are recommended. The author expresses a doubt concerning their injurious effect, and states that “ the popular notion that they tend to produce erysipelas, is without foundation.” As a broad principle it may be regarded as very questionable advice, but admitting their usefulness, and occasional permissibility, the caution to avoid injury to the deep aponeurosis, in their introduction, ought to be mentioned. But in these pages, he not only gives his own views but those of other writers, so that the reader may have an opportunity of contrasting different methods of treatment in the management of their own cases, and of judging of their relative merits.
The volume begins with a chapter on Diagnosis, in which we learn the method of proceeding to arrive at a correct opinion of the nature of any given case. This forms an introduction to the rest of the work, which is divided into ten chapters. In the first chapter the subject of inflammation is freely discussed, the varieties of the inflammation such as what has been termed healthy and unhealthy. The former term might be considered contradictory, but it is very generally employed, and may be correctly regarded as indicating that condition, in which the morbid tendency to destruction of a part inflamed is resisted by a conservative force, ever present to save from destruction parts injured through accident or disease. Different degrees of inflammation, causes, nature, pathological changes, and termination are all given, together with special methods of treatment. The next chapter is on wounds, their varieties, hæmorrhage, nature's method for its control, closure of vessels, formation of thrombus, treatment of hæmorrhage from wounds, the various methods employed. These the author fully discusses, and after a careful description of compression, cauterization, torsion, acupressure, and the use of the ligature, he compares the relative value of each method, and gives a verdict in favor of the ligature ; in this the majority of practical surgeons of any experience will agree; still, it must be conceded that there are circumstances in which the use of torsion, or the needle, will be advantageously employed. In continuation of this subject of hæmorrhage from wounds transfusion is mentioned and the mode of performing it described. The treatment of wounds, with a description of the various kinds of sutures is next given, and then we have a description of the after treatment of wounds. In this the author
admits the advantages to be gained by the antiseptic method, which he declares he is satisfied from his own observations to be superior to all other methods of treatment. The different kinds of wounds are next given : these are considered under the headings of incised wounds, lacerated and contused wounds, contused wounds proper, punctured wounds, and poisoned wounds ; under this heading will be found dissection wounds, malignant pustule, foot and mouth disease, glanders or farcy, hydrophobia, bites of poisonous insects and venemous snakes, and lastly gun-shot wounds. This is a most interesting chapter, especially that portion relating to the poison wounds of insects and snakes, as so little is to be found on this subject in other surgical works.
Injuries of the head form the subject of the third chapter, in which will be found first, a few general considerations, and subsequently, a description of injuries of the scalp, gun-shot wounds of the scalp, and their various complications, such as erysipelas, injury to the cranial bones, and injuries to the brain or its membranes, &c. The fourth chapter is devoted to wounds and injuries of the chest and abdomen ; in the fifth chapter wounds or injuries of the extremities are taken up and discussed. In chapter six we have the diseases of the abdomen, such as morbid growths, cysts, fistula, ascites, in which the method of performing paracentesis is described. Intestinal obstruction, intussuseption, organic change in the walls of the intestine, cicatrices, &c., and in this connection is considered the advisibility of colotomy. In giving the statistics of colotomy, the author includes one case only of lumbar colotomy, as having been performed in Montreal, whereas there have been published five cases by the writer, and one by Dr. Ross. As to the results of these six cases, the first a woman, operated on by Dr. Fenwick, died ten months after the operation from a severe attack of cholera. The second, woman, operated on by Dr. Ross, is, we believe, still living. The third, a child of eleven years, operated on by Dr. Fenwick, for epithelioma extending up the rectum above the reach of the finger, is, or was alive two months ago, November, 1878. The fourth case was in a syphilitic woman. There was a long meso