Beaven Rake
1886 The Lancet  
581 and produced very little impression on either of these structures. CASE 9.-A young man who had shot himself through the head in a railway carriage was handed over to the police on his arrival at Warrington, on his own confession, that he had attempted his life. Declining the use of a cab, he walked to the local infirmary, a distance of a quarter of a mile, and was quite conscious and collected on his arrival at that institution. On being examined, a small circular wound was found about an
more » ... ch and a half above the right external angular process of the frontal bone, just behind the temporal ridge. With the exception of some nausea and vomiting, there was no evidence of brain lesion present, but a small punctured fracture could be discovered in the skull, and on exposing this, the brain could be seen to be wounded, " the track of the bullet extending to an unknown depth." He survived till the 30th of the month-i.e., nearly six days,-having had a good deal of twitching and vomiting in the meanwhile, and his last night was distinguished with almost continuous convulsions. He had been more or less conscious towards the end. On section a fragment of the inner table was found lying flat between the dura mater and the arachnoid. The surface of the latter, where it covered the right hemisphere, was infamed and covered with pus, and on slicing the former the bullet was found to have entered the brain in the line of the fracture, and to have taken a direction downwards, mwards, and slightly backwards through the. genu of the corpus callosum to lodge in the anterior part of the corpus striatum. A somewhat truncated "remainder" (I can scarcely call it a fragment) of the bullet was found at this spot, and it, as well as its sounder fellow of the same batch are well represented in Fig. 2 . FIG. 2. Revolver bullet and its truncated remnant. Commenting on this case in the British Medical Journal of April 16th, 1881, Mr. Richmond, under whose (subordinate) care it occurred, truly observes that its history is somewhat phenomenal. The patient not only walked firmly from the railway station to the hospital, but he retained consciousness for sixty hours afterwards, and, comparatively speaking,'fair health up to within the last twenty-four hours of his life.. Even then the gravest symptoms appeared to be attributable to the changes that were produced on the surface rather than to those that took place in the interior of the brain. Readers of works on military surgery must be so well acquainted with instances in which bullets or other articles become encysted within the brain for considerable periods that I need not enter into any details respecting them here. a case of successful cataract extraction from a lunatic. I have therefore thought that a short note of a similar operation, performed on a patient who was suffering simultaneously from leprosy and insanity, might perhaps be of interest. G-, aged thirty, a Hindu immigrant, was admitted to the Trinidad Leper Asylum on Sept. 10th, 1883, with a history of anaesthetic leprosy of thirteen years' duration. There was characteristic deformity of the hands. On Jan. 8th, 1885, it was noticed that he talked incessantly, and was often very noisy, causing much annoyance to the other patients. He had been more or less demented since his admission, but had become much worse lately. He was not dangerous to himself or others. On Feb. 26th the left wrist was found to be much swollen. There was effusion of fluid, and the I hand was flexed towards the radial side. Grating was felt in the joint, and the carpus could be dislocated forward on to the anterior surface of the radius, reminding one of a case of Charcot's disease. There was no pain on manipulation. The carpal bones appeared thickened, and the fingers were shrivelled and contracted. There was no history of injury, and no other joints were similarly affected. He said this condition of the wrist had come on soon after the onset of the leprosy. On May 7th he was found to have double cataract. He could see a very little with the right eye, but not at all with the left. He appeared to have lost the sight of the left eye for a long time, but only recently to have noticed the impairment of sight in the right eye. As the conjunctiva appeared to be totally anæsthetic, the left cataract was extracted without chloroform by the modified linear operation. He made no complaint of pain. On opening the capsule a little soft whitish material escaped, but the greater part of the cataract was yellowish and very hard. The extraction was completed with the help of the scoop. As soon as the pupil was cleared he was able to see a little. The eye was treated in the usual way with atropine solution and cold water dressings. Fragments of the cataract were stained with magenta, but no leprous bacilli could be found. Soon after the operation he took off the bandage himself, but it was at once replaced, and he did not take it off again.-9th : Pupil clear. Not much injection. Sees a little. Atropine repeated and bandage replaced.-12th: Pupil clear. Wound has gaped a little, and there is slight prolapse of iris. Atropine repeated.-14th: Conjunctiva very injected. Prolapse almost the same. No complaint of pain.--19th: Iris has settled down flat. Conjunctiva still injected. Sees hand when held up, and touches it when told to do so.-23rd : Injection gone. Iris settled.-June 2nd : Firm cicatrix. No prolapse. Pupil clear. He walks with a jerky movement, lifting his feet high from the ground.-9th : The right cataract was extracted in a similar way, but was found to be softer than the left, and there was some difficulty in getting it to present well. Escape of vitreous was noticed after the operation. Atropine was used, and both eyes at once bandaged.-16th: Suppuration going on. Protruding vitreous opaque. Pain and cedema of lids. Left eye unaffected.-23rd : Right eye settling down. Pain and inflammation gone, but eye contracted and blind. The left eye was quite unaffected, so the bandage was discontinued.—March 15th, 1886: Counts fingers with left eye at 10 ft. Cicatrix firm. Small pterygium growing on each side of cornea. He is still demented, but quieter than he was, and will generally answer questions rationallv. This case seems interesting as illustrating the fact that cataract extraction may be successful under such adverse conditions as the restlessness of a lunatic and the presumablv impaired nutrition of a leper, though this latter point I am prepared to doubt. I am collecting statistics, which I hope to publish at some future date, to show that operations on lepers are more successful than is commonly supposed. The complete local anaesthesia due to the leprosy served well in place of a local anaesthetic. I had hoped for success in both cataracts, but perhaps I was in rather too great a hurry to extract the second. Had 1 waited a few months longer till it became more mature, there would probably have been less difficulty in extraction, and the escape of vitreous might have been prevented.
doi:10.1016/s0140-6736(00)49756-4 fatcat:emwmbz4jmzbjrlrgjnfn7dryqu