A CASE OF BULLET WOUND OF THE BRAIN

William Sheen
1904 The Lancet  
825 further extension of the lesions. Gradually all the sloughs 7 were removed by fomenting and a large raw area was left extending from just below the right ear down to the right a breast. As the area was so large skin grafting was resorted 1 to but the grafts refused to hold and a subsequent trial gave I no better results. Boric acid ointment was then applied for a time, while later red lotion on lint gave excellent 1 results. Convalescence was slow and protracted, the part granulating very
more » ... owly indeed. Her general condition became much better in hospital, iron having been persevered in steadily, except for a slight rheumatic attack she improved daily. Her temperature throughout was slightly above normal, usually about 990 F. Twice, however, abnormal temperatures were registered, once 110° and again 105", but on both occasions when the nurse again took the temperature it was found to be normal. The cicatrix several times broke down when nearly completely healed, but eventually after nearly five months in hospital she was discharged with the part quite healed but with an exceedingly large disfiguring cicatrix, or rather cicatrices, on her neck and breast. Banff, N.B. Surgeon to, and Medical Officer in charge of, the Electrical Department, Cardiff nfirmary. A MAN, aged 23 years, a stoker, was struck on the forehead by a revolver bullet while standing on the cab of his engine. The bullet was fired from a garden near the railway line at a distance of from 25 to 30 yards. The man fell but loss of consciousness was only momentary. The wound was enlarged and probed without result. He walked to a train and was taken a distance of about 20 miles to the Cardiff Infirmary and was admitted there at 6.30 P.M. on Nov. 28th, 1903, three and a half hours after the accident. Detailed examination immediately after admission showed an entire absence of symptoms. There was no evidence of the position of the bullet. Three hours later vomiting occurred. In the morning he was semi-conscious, grunting, moved his limbs when told to, and said " yes and "no." The reflexes were unaffected. The pupils were equal and were of medium size and reacted. Slight paralysis of the lower side of the face was present on the right side. Thetemperature was 99' 8° F. and the pulse was slow and full. The head was shaved. A skiagraphic view showed indistinctly the position of the bullet. Antero-posterior and lateral x-ray photographs were taken and these being developed the man was anaesthetised on Nov. 29th at 3 P.M. In the intervening period his temperature had gradually risen and was now 102°. The entrance wound was situated 2-5 5 centimetres to the left of the middle line and 2'5 centimetres above the orbital arch ; it had contused edges and had been enlarged by a crucial incision. The bone and dura mater had been lacerated and brain substance oozed from the wound. There were no fissures radiating from the wound in the bone. A suitable " toilet " was made of the wound and it was partly closed, a gauze plug being left in its centre. The developed plates showed the bullet well, but owing to its position no attempt was made to extract it. The subsequent progress was one of slow general improvement complicated by the incidence of paresis of the right arm and right side of the face with " motor " aphasia, symptoms all of which gradually subsided. The temperature reached normal on the fourth day after operation and 1 A paper read before the Cardiff division of the South Wales and Monmouth branch of the British Medical Association. -eniained there. Examination of the optic discs by Mr. F. P. S. Cresswell on Dec. 1st showed them to be healthy, md a blood count by Dr. Cyril Lewis on Dec. 2nd gave 10,400 leucocytes per cubic millimetre. There was loss of control :)f the excreta until Dec. 3rd. The paralysis of the face was limited to the lower part, the associated movements being 3;ood. Weakness of the right arm was noticeable on Dec. lst and aphasia on the 2nd. The paretic symptoms became more marked during the next four days, when slow improvement commenced. The arm showed wrist-drop, dynamometer grip nil, inability to shrug the shoulder, and ability to move the elbow-and shoulder-joints and to rotate the forearm. No sensory disturbances were noted at this time but later there was numbness in the little and ring fingers which after the second operation extended to the middle and index fingers. The aphasic symptoms were of the ordinary "motor" type. Whilst unable to speak, to repeat or to name objects, comprehension was perfect and he was always able to indicate the number of syllables in a word. No disturbances of the special senses were present. The stereognostic sense was good. After passing through a state of mental confusion characterised by laughing and " silliness " he completely regained consciousness by Dec. 7th. The first person he recognised was the man who shot him ; he called out this man's name and indicated a dislike to his presence. On Dec. 16th the dynamometer grip was right 40, left 60, and the facial paralvsis was almost gone. The aphasic symptoms disappeared more slowly but by the end of December only occasional hesitation or difficulty in getting out words remained together with confusion and stuttering when he embarked on a long sentence. He remembered his accident and admission to the infirmary, then there was a blank for three or four days, when he remembered his mother sitting by his bedside. The only further points to be noted up to the date of the second operation were intermittent attacks of left parietal and frontal headache and on Dec. 18th a bad attack of general headache with temporary increase in the aphasia and arm weakness ; this passed off. On Jan. 16th he got up and on the following day slight weakness of the right leg was noted, together with a tendency to throw out the right foot when walking. The right knee-jerk was found slightly more marked than the left ; previous examinations had shown no difference. The second operation was performed on Feb. 9th-i.e., ten weeks after the injury. The forehead wound was soundly healed. Several skiagrams had been taken and a stereoscopic view was prepared showing the position of the bullet. Chloroform was administered by Dr. W. G. Williams. Mr. A. Brownlee, the resident medical officer, assisted, and Mr. Martin, Dr. T. W. Parry of Ferndale (who first saw the patient), and other gentlemen were present. A flap was turned down behind the left ear and a one-inch disc of bone was removed above and behind the meatus. This bone opening was enlarged downwards and forwards, the dura mater was opened, and search was commenced for the bullet by entering a probe 3'5 centimetres above the meatus and 2'5 centimetres behind the inter-meatal line and passing it in in the horizontal plane of the head for a depth of 6'7 centimetres. The bullet not being felt, Hedley's telephone probe was passed in the same line and after feeling a moment a rather doubtful tap was heard. The probe was withdrawn and a pair of ordinary dressing forceps was passed in and felt the bullet which bobbed about in an elusive way at the end of the forceps, suggesting the possibility of its being in a cavity. A first attempt to grasp and to remove it proved unsuccessful but on reintroducing the forceps it was seized and removed with a little adherent brain substance. The length of forceps introduced measured 6'5 centimetres from the general skull snrface. As there was considerable increase of intracranial tension some of the brain substance had to be removed before the dura mater could be brought together. The disc of bone was replaced and the wound was closed with drainage. The after-progress was uneventful. There was no paralysis or aphasia. The tube was removed on the day following the operation and the stitches were removed on the eighth day when the wound was found to be healed completely. Exactly three weeks from the operation the man got up. There was still slight weakness of the right arm and leg. The dynamometer grip was right 60, left 90. Dimness of vision was complained of, particularly in the right eye. On Feb. 22nd Mr. Cresswell
doi:10.1016/s0140-6736(01)31884-6 fatcat:gl7d5y7p4vcijec2atcpdeetuy