♦ KNOWLEDGE 



[Oct. 2, 1885. 



blood, arose and left the house. He walked about an 

 fighth of a mile, and then got upon a horse-car while 

 in motion and took a seat inside. When called iipon 

 by the conductor to explain the nature of hi.s injury, 

 he could not speak, although he knew what he wanted 

 to say. After riding about three-quarters of a mile he 

 was put off the car by the conductor. He distinctly re- 

 membered having swung himself from the car with the 

 aid of his right hand. After walking about an eighth 

 of a mile farther, he stood upon the corner of the street 

 till a policeman came and conducted him about one-third 

 of a mile to the station-house. There he was questioned 

 by the officer in command, but was unable to speak. Not 

 long after he became unconscious. He was admitted into 

 the hospital at about 8 a.m., when his wound, from which 

 l)rain-matter was oozing, was dressed antiseptically. 



Preparatory to the operation, the patient's scalp was 

 shaved. He was then etherized. A flap of gutta-percha 

 tissue was fastened to his forehead to protect his eyes 

 from the antiseptic solution of bichloride of mercury, 1 

 part to 1,000 of water, with which the parts were to 

 be irrigated during the operation. The bullet-hole, of 

 email size, was very nearly in the centre of the fore- 

 head. The skin at the right margin of the opening 

 was more ragged than at the left side. The epidermis 

 was blistered off for a little distance from the opening. 

 There were no powder grains in the skin. The soft parts 



To ascertain the direction of the wound through the 

 soft parts and bone beneath, a silver probe with a 

 large knob was passed into the wound perpendicularly 

 to the surface of tlie skull. To pass the probe throiigh 

 ♦^he opening in the bono I found it necessary to direct 

 its course outward at an angle slightly divergent from 

 the median plane of the head. In passing the probe 

 thus far, the right margin of the opening in the skull 

 was felt to have a depressed shelving-edge. An incision 

 an inch and three-quarters long was then made from 

 below upward to the centre of the bullet-liole. This 

 incision was parallel to the median line, and just to the 

 left of it. 



[Here follows an account, occupying three long columns, 

 of the operation for tracing the path of the bullet (which 

 had passed to the back of the skull, and had thence been 

 deflected towards the left), and extracting the bullet 

 when found. The account is full of matter interesting 

 only to surgeons.] 



The operation was completed in about four hours from 

 its commencement, the greater portion of the time having 

 been spent in stopping the cerebral hsemorrhage. The 

 following-named members of the house staff were present 

 at- the operation : Dr. R. T. Morris, Dr. J. R. Conway, 

 junr.. Dr. W. W. French, Dr. J. H. Woodward, Dr. H. N. 

 Williams, Dr. P. Oppenheimer, Dr. H. S. Wildman, Dr. 

 H. Herman, Dr. H Biggs, Dr. E. Hurd, Dr. C. F. Roberts, 

 ,and Dr. W. G. Rutherford. 



The patient's general condition after the operation was 

 about the same as when it was undertaken. He was 

 transferred to the Sturgis Pavilion, special orders being 

 given that he should not be allowed to suffer from reten- 

 tion of urine, and that pain should be relieved by suffi- 

 cient doses of morphine. 



At nine o'clock p.m. the patient's temperature was 

 101° Fahr., his pul.se 120, and respiration 32. A hypo- 

 dermic of Magendie's solution of morphine, seven minims, 

 was given ; his urine was drawn by gum-elastic catheter. 



January 25. — The patient is in about the same condi- 

 tion as before the operation. He is semi-comatose, still 

 hyperKsthetic upon the left side of the body, and irritable 



when aroused. He drinks milk with an apparent relish, 

 and puts out his tongue when told to do so. 



[From this time onward there was a gradual improve- 

 ment and final recovery.] 



In treating the hernias cerebri it was my aim to deal 

 gently with them, at the same time keeping the wounds 

 aseptic. In the period of their formation no pressure 

 was made upon the brain protrusions. I looked upon 

 their production as in part duo to swelling of the cerebral 

 tissue as a result of its injury, and based my non-inter- 

 ference upon the intolerance to pressure of acutely 

 swollen or inflamed wounded tissues. From this point 

 of view, the openings, of considerable size, in the skull 

 were a benefit in the treatment of the deep brain injury 

 in its early stage rather than a disadvantage. In a later 

 stage, however, when the brain protrusions had reached 

 their greatest size and the course of the wounds had 

 become chronic, I thought it advisable to aid the 

 recession of the hen its by gentle and evenly applied 

 pressure. 



On May 22, 1884, I exhibited Knorr at Bellevue 

 Hospital to a number of physicians. He was then, so 

 far as could be judged, in perfect health. Apart from 

 the scars upon the patient, the only abnormality discover- 

 able was a limitation of the visual field for green and red 

 observed by Dr. W. F. Mittendorf. Inasmuch as this 

 feature was common to both eyes, it is questionable 

 whether it was caused by the injury. 



The bullet entered at the centre of the forehead, an 

 inch and a quarter above the upper level of the eye- 

 brows ; it passed in a straight line through the brain, and 

 was then deflected to its place of lodgment — an inch and 

 a half to the left of the posterior medain line. The probe 

 having been passed through, the straight portion of the 

 wound was eliminated in the further search for the bullet. 

 The probe was then passed through the deflected course 

 after the same method as employed for the exploration 

 of a tortuous wound. The bullet could have been fol- 

 lowed about three inches farther upon its deflected 

 course till arrested by the tentorium, the end of the 

 probe being exposed by a second counter-opening in the 

 skull. 



The bullet cut upon the superior longitudinal sinus 

 and penetrated the brain in the first frontal convolution, 

 just at the edge of the hemisphere, win re tlu^ convex 

 surface joins the inner surface; tr,ivtr>ii)L;- tin' I'lMJn- 

 substance of the hemisphere, it emeri^iMl mihI lul-rd in 

 the superior parietal convolution. The ilistmicd liitwcen 

 the two openings in the brain, in a straight lino, was six 

 inches and a quarter. 



In order to locate the injured cerebral artery with 

 reference to the course of the ball, I carefully marked 

 upon a cadaver the points of entrance and emergence of 

 the bullet. I then removed a section of the skull to 

 enable me to pass a straight-edged, long knife through 

 the brain, in a straight line between these points. Upon 

 removal of the brain, it was found that the cut in the 

 first frontal convolution was down to a large branch of 

 the anterior cerebral artery, lying about half an inch 

 from the surf ace. of the brain. 



The patient left the hospital, where he had for a hmg 

 time been retained simply for observation, on June 30, 

 1884. 



About August 1 the patient went back to work at his 

 old employment in a butcher's shop. He remained at 

 work during the exceptionally hot weather in the early 

 part of September. 



On September 12, between twelve and one o'clock in 

 the morning, Knorr received a heavy blow in the anterior 



