EPILEPSY; INFANTILE CONVULSIONS, ETC. 1091 Strontium bromid has recently been recommended and possesses some advan- tages over the other salts of bromin. It is less liable to disturb the stomach, and is not so prone to cause acne. It should be given in the same doses as sodium bromid, and can be continued for a considerable length of time with- out injury. I have notes of one patient who took sodium bromid for many months without arrest of the attacks, but when strontium bromid was given the attacks ceased, and there was no recurrence for eighteen months. Magnesium bromid has been used at the Infirmary in sixteen cases in doses of from 5 to 20 grains (0.32-1.3) three times a day. It has a disagreeable taste, but seems to have no depressing effect. This salt exerts an undoubted influence in controlling the attacks both as to severity and frequency, but it apparently causes a greater liability to facial eruptions than the other bromids. Potassium bromate, which is analogous in its chemic constitution to potassium chlorate, was manufactured for use at the Infirmary at the suggestion of Dr. Weir Mitchell. It was given in twelve cases and proved unsatisfactory.1 Cannabis indica has been recommended by Gowers and Russell Reynolds as being of occasional value, and I have recorded one case myself in which the use of this remedy was followed by complete arrest of the attacks after the broraids had failed completely. Its use is particularly indicated in cases in which migraine is present, and it does good in some eases of petit mat. Chloral hydrate is of little or no value alone, except in the status epi- lepticus. It may be given in combination with the bromids, and Seguin has shown that by combining this remedy with the bromids, much smaller doses of the latter become necessary. Iron is to be recommended in cases in which anemia exists, but it is not wise to push its administration too far. Some writers believe that its use is contraindicated, but I have never seen ill effects therefrom. Conium, formerly recommended, is but little used now, and is not to be depended upon, alone. Copper was latterly employed in the form of the ammonio-sulphate, but it is now almost never used. Digitalis is probably the best of the organic remedies, and it is frequently of value when the bromids are not well borne. It is useful in combination with the bromids, and the most desirable form of administering it is the infu- sion. It seems to counteract to some extent the depressing influence of the bromids. Digitalis has recently been given with advantage by Naunyn2 in cases of senile epilepsy in which anemia of the brain was present as a result of arterio-sclerosis. Duboisia has been employed in the past year or two, but it is chiefly useful in the treatment of hystero-epilepsy and of epileptic insanity. Ergot has been recommended, but it is of doubtful value, and in the cases in which it was thought to be beneficial it was used in combination with the bromids. 1 See article on "Treatment of Epilepsy," by Guy Hinsdale, M. D., International Medical Magazine, March, 1892. 2 La Semaine medicale, Nov. 29, 1895. 2 La Semaine medicale, Nov. 29, 1895. 1092 AN AMERICAN TEXT-BOOK OF THERAPEUTICS. Horse-nettle (Solanum Carolinense) has been recently brought forward and extolled as a remedy. It has been given a trial at the Infirmary with entirely unsatisfactory results. In none of nine cases in which it was employed was any benefit observed, while some were made worse. Hyoscin hydrobromate is useful in conjunction with the bromids, and when there is a tendency to maniacal excitement. Hydrobromic acid, recommended by H. C. Wood, is of but comparatively little value. To be efficient it should be given in milk in doses of at least one or two fluidrams (4.-8.), but its taste is so intensely acid that the drug is not well borne by the stomach. It has the advantage of not being depress- ing, and of not being so likely to cause acne-probably because of the com- paratively small amount of bromin that it contains. One fluidram (4.) of the dilute acid is equivalent to only 9 grains (0.58) of potassium bromid. Potassium iodid is of advantage when there is a syphilitic history, and it should then be given in large doses. Naphthol has been found beneficial from its action as an intestinal antiseptic. Beta-naphthol is the most eligible form. Amyl nitrite has proved of great value in arresting the attack. This fact made it seem probable that a more stable remedy of this class would prove efficacious as a preventive. On this ground potassium nitrite has been used, and in 1880 a test was made with this remedy by Dr. Hinsdale at the Infirmary for Nervous Diseases, under the direction of Dr. Weir Mitchell.1 The results were encouraging, but the remedy proved too depressing in doses of from 4 to 5 grains (0.26-0.32) and caused cardiac irritability. Nitroglycerin has not been sufficiently successful to encourage its use. At the Infirmary a series of nineteen cases were treated with this remedy for periods ranging from six weeks to six months, and the benefit was very doubtful. The nitrites all act by causing a fall in blood-pressure through relaxation of the walls of the peripheral vessels, but their influence is too evanescent to be of great value. Opium.-Flechsig's treatment of epilepsy with opium, followed by large doses of bromids, has been employed with some success, but we have not tried it. The plan is to give increasing doses of opium until at the end of a week 15 grains (1.) or more are taken daily. At the end of six weeks the opium is discon- tinued, and 2 drams (8.) of one of the bromids are given daily. After con- tinuing thus for two or three months the dose of the bromid is gradually brought down to 30 grains (2.) a day. The administration of the bromid marks the cessation of the fits in a considerable number of cases. Favorable reports on this method of treatment have been made by Joseph Collins,2 who thus treated fifty cases. Nearly all were benefited, but relapsed later. No bad effects resulted from the use of opium, but coffee and active cathartics were employed as adjuvants to the treatment. Potassium permanganate has been given with successful results in cases in which intestinal putrefaction played a part. 1 American Journal of the Medical Sciences, July, 1880. 2 Medical Record, vol. xlvi. p. 355. EPILEPSY; INFANTILE CONVULSIONS, ETC. 1093 Silver nitrate at one time had a decided reputation in the treatment of epilepsy, and many patients display to the present day the effects of its administration, as shown by the blue discoloration of the skin. It is now generally agreed that this remedy is absolutely useless. Strychnin is injurious in most cases of epilepsy, causing irritation of the cerebral cortex. If given in large doses it excites an increase in the number of attacks. It is sometimes useful, however, in moderate doses after a pro- longed course of bromid. Sulfonal has been recommended, but is of comparatively little value. It was administered in thirty-three cases of epilepsy at the Infirmary, with advantage in only a small number. It was found impracticable to give more than 6 or 8 grains (0.39-0.52) three times a day on account of the soporific effects of the drug. It is of use, however, when the bromids have to be discontinued. Trional has been given at the Infirmary in doses of from 5 to 8 grains (0.32-0.52) three times a day. In two cases the drug was continued for four months without apparent ill-effect. In some cases there was marked benefit. This drug will probably prove useful in cases in which the bromids are not well borne. Zinc oxid has been given a fair trial, but has proved of so little value that it is not to be recommended. Since animal extracts have been used in the treatment of various diseases, efforts have been made to apply the same principle to the treatment of epilepsy. It was discovered that antirabic treatment seemed to have a good influence upon epileptics, and this plan was recommended by Charcot.1 Gibier2 reported the case of a patient in whom antirabic treatment made the attacks worse, but " nervin " (an extract of gray nervous tissue) did well in two other cases. One case in which four or five attacks occurred daily and an epileptic state was almost constant, was freed of the attacks while taking nervin. In another case in which from two to four attacks occurred daily, the number was reduced to one every two or three days. There have been but few additional reports on the treatment of epilepsy with animal extracts, so that it is probable that the results have not fulfilled the original expectations. Bourneville and Cornet3 treated thirty cases of epilepsy for six weeks with subcutaneous injections of testicular fluid. In eight there followed a diminu- tion in the number of fits ; in twenty the number of fits increased ; and in two the treatment was not fully carried out. In no case did amelioration of the mental symptoms result. . The question has been raised whether, after all, it is advisable in chronic cases to put an end to the convulsions, or even reduce them to a minimum. It has been maintained that in order to accomplish this result the amount of drugs necessary will produce dulness of the mental faculties and deterioration in the intelligence, and that it is probably bettei' for a patient to have a certain 1 Lancet, London, May, 1892. 3 Recherches cliniques et therapeutiques sur I'Epilepsie, etc., Paris, 1894- 2 Therapeutic Review, 1893. 1094 AN AMERICAN TEXT-BOOK OF THERAPEUTICS. number of convulsions and to have sufficient intelligence to care for himself in the intervals between the attacks, and even to be able to do some useful work, than to have the attacks reduced to one-half, or even entirely stopped, were it possible. Undoubtedly in some instances drugs are pushed so far as to produce impairment of intellect and memory, but such a result is uncom- mon ; and the fact must not be lost sight of that the more numerous the con- vulsions, the greater is the resulting impairment of intelligence and intellect. Those who have had the opportunity of seeing patients who have not been treated with drugs find that the intelligence is in inverse proportion to the frequency of the attacks, and it is my own belief that it is better to use every means to reduce the number of attacks, provided that undue amounts of drugs are not administered. A carefully conducted test of some of the remedies already named has been made in the treatment of cases of chronic epilepsy in the wards of an insane asylum by Dr. E. D. Bondurant.1 The patients were all adults, from twenty to fifty-one years of age, and had suffered from epilepsy for many years. A condensation of the results of observations before, during, and after treatment is given herewith: Acetan ilid .... (17 cases) Antipyrin (8 cases) Sodium biborate . . (14 cases) /3-Naphthol .... (6 cases) Strontium bromid . (10 cases) to Ji. Jh tO J- ' O O O CS Cn C5 No. of convulsions during 30 days pre- ceding treatment. W 00 Hi 00 Q0 w °° C> 00 00 No. of convulsions during 30 days of treatment. 03 C tO tO !-> OO g Ji. to H-* 05 -<l CO tO No. of convulsions during 30 days suc- ceeding treatment. Cn k-* CO CO t-' IO CO O Cn Ci O 4- Oi Average No. of at- tacks per month when taking no medicine. o co o co O C3 o Oi O Daily dose in grains. None in 15 cases; improved in 2. 2 improved; 5 un- changed ; 1 worse. 2 improved ; 11 un- changed ; 1 worse. None. 2 improved ; 5 un- changed ; 3 worse. Effect upon the gen- eral mental and physical condi- tion. Surgical Treatment.-For many years surgical operations have been per- formed for the relief of epilepsy, but they have been undertaken more or less empirically until within the past few years. Formerly trephining was done without any attempt at localizing the seat of the disease, and old works on medicine refer to openings having been made into the skull for the purpose of releasing vapors. Since cerebral localization has been made an exact science, many operations for epilepsy by trephining have been performed, but the results have not been thoroughly satisfactory. Frequently the operation is followed by an arrest of the convulsions for several months, but it is well known that almost any operation is followed by temporary relief of the symp- toms for which it is done. J. William White has collected ninety cases in 1 American Journal of Insanity, July, 1894. EPILEPSY; INFANTILE CONVULSIONS, ETC 1095 which trephining has been done and no lesion was found, and in which yet marked relief followed.1 He also records instances in which benefit followed tracheotomy, ligation of the carotids, and incision of the scalp. A cure cannot therefore be regarded as established after trephining until several years have elapsed without a convulsion. Five years without recurrence is the time required by W. W. Keen to constitute a cure. The cases in which surgical operations may be done include, first, those in which there is reason to believe that some gross lesion exists, either the result of traumatism, giving rise to irritating cicatrices or depression of the skull; or those in which a tumor or cyst in the motor area produces so-called Jacksonian or focal epilepsy; and, secondly, those cases of idiopathic epilepsy in which the character of the convulsions seems to indicate irritation of some area that can be localized. The traumatic cases are those in which there is evidence of injury-as, for example, a cicatrix upon the scalp or a depression of the skull. When there is marked tenderness of a cicatrix upon the scalp, or when an attack can be induced by pressure upon such a cicatrix, it is best before trephining to remove this and any adhesions it may have formed with the skull. If excision of the scar fails to relieve the symptoms, then the skull should be opened. In tre- phining, should no irregularities be found on the under surface of the button removed, it is always best to incise the dura and examine the underlying convolutions. Walsham2 reports 82 cases in which trephining was performed for epi- lepsy, with 65 recoveries and 17 deaths. In 47 cure was reported-a much larger proportion than would be expected at the present day; but it is prob- able that the cases were not observed for a long time after the operation. In 13 improvement resulted, and in 4 there was either no improvement or aggra- vation. In only 16 of the cases was no lesion discovered. The accompanying table, compiled for me by Dr. Guy Hinsdale, gives the result of trephining in 121 cases of idiopathic and focal epilepsy. Dr. Hins- dale has examined all of the available literature covering the past six years, and has included in his table all cases that could be found except those in which the report was incomplete.3 Analysis of 121 Cases of Epilepsy Trephined. Traumatic. Idiopathic. Cessation of attacks for five years or over .... 5 0 Cessation of attacks for from two months to five years .... .... 22 4 Improved .... 21 3 Unimproved .... 42 11 Died from the operation .... 2 2 Undetermined .... 8 1 Total .... 100 21 1 " The Supposed Curative Effects of Operations per se," Annals of Surgery, Aug. and Sept., 1891. 2 St. Bartholomew1s Hospital Reports, vol. xix. p. 127. 3 The first 100 are cases of focal epilepsy, the remainder cases of idiopathic epilepsy. 1096 AN AMERICAN TEXT-BOOK OE THERAPEUTICS. No. Reporter; reference. Sex. Age at trauma. Age at opera- tion. Nature of trauma. Frequency of attacks. Nature of attacks. Operation. Under ob- servation after op'n Result. 1 Taylor, J. M., Jour, of Nerv. and Men. Dis., April, 1895. m. 3 14 Fracture of skull from fall. Right parietal. Spasms in opposite arm, forefinger, and thumb. Trephining by T. G. Morton. 8 years. Cure. 2 Wm. Butlin, Br. Med. Jour., Nov. 17,1894. m. ad. ad. Fell 8 feet on the head. Began in 4 days; 17 in 1 day. Followed soon after accident. Trephining; clot re- moved. 6 weeks. No return. 3 Kellogg, Mod. Med., May, 1894. m. 8 14 Fall on the head more than 6 years before. Often daily. Jacksonian. Trephining with De- Vilbiss saw. 20 months. Improved, but has petit mal. 4 Chapman, J. T., Med. News, Feb. 24, 1894, and personal com- munication. m. 11 14 Fracture of parietal from blow on head. Began in 3 weeks; frequent; 6 in 1 day.. Violent. Trephining; indura- ted membranes ex- cised. 6J years. Gradual cure. 5 Carline, British Med. Jour., Feb. 24,1891. m. 12 17 Fracture of skull. Began in 1 year; 4 or 5 daily or oftener. Left-sided, starting in left side of mouth. Trephining over rt. motor area. 5 months. No return. 6 Mynter, Annals of Surg., May, 1894. m. 12 24 Compound commi- nuted fracture of left frontal. Status epilepticus. Head drawn to left; attacks began at 18th year. 3| years. 2 years after 2d oper'n. Relief; relapse; 2d operation; cure. 7 Blois, Gaz. des Hop., June 14,1894. f. 6 19 Depressed fracture of skull from fall. Began at 14; 2 in 1 day. Violent. Trephining; depress- ed bone removed. 18 months. Entire relief; 1 at- tack 14th day, and none since. 8 Huselton, Pittsburg Med. Rev., Apr., 1894. m. ad. Depressed fracture of skull 12 yrs. before. Jacksonian. Thickened bone ex- cised from 1. frontal. 9 months, Relief. Cessation of attacks. 9 Brenner, Centralbl. f. Chir., July 7, 1894. m. 10 15 Injury to right parie- tal by hatchet-blow. First attack in 6 months. Left thumb and left upper extremity. Trephined. 1 month. Recurrence. 10 Packard, J. H„ per- sonal communica- tion. m. 14 54 Blow on the head from a brick; un- conscious. Began in 1 year; ir- regular, infrequent. Unconsciousness, with biting of the tongue. Trephined left parie- tal. Temporary relief. Recurrence. 11 McCosh, Ann. of Surg., May 6, 1894. f. 7 5 or 6 daily. Trephined over left motor area. 2 months. Cure (?) after subse- quent typhoid fev. 12 Hadra, ibid. m. 30 Local, then general. Trephined twice. No relief. 13 Hadra, ibid. in. 6 18 Fall and "brain- fever." Began in left wrist. Trephined twice. Died by accident 5 weeks later. 14 Sherrington, Br, Med. Jour., Nov. 4,1893. m. 15 From 4 to 15 daily. Jacksonian. Trephined twice. Relapse. 15 Darby, J. I., Virg. Med. Mo., May, 1894. m. 4 19 Fracture of left parie- tal from blow. Began at 16; fre- quent. Severe convulsions. Trephined; dura de- tached. 10 years. Perfect cure. 16 Darby, ibid. m. 20 27 Depressed fracture of left upper frontal. Began at 24; fre- quent. Severe convulsions. Extensive trephining. 3 months. No return. 17 Barber, C. F., Brook- lyn Med. Jour., Oct., 1893. in. 16 32 Depressed fracture of right frontal; mule-kick. Monthlv, then week- ly. Jacksonian. Trephined at 24 by Hammond. 8 years. Improved, then re- lapsed. 18 Wells, T. L., ibid. m. 6 24 Injury to occiput from fall. Began at 16; 2 to 15 monthly. Grand mol, maniacal. Trephined. 1 month. Cessation. 19 Johnston, D.W., Edin- burgh Med. Jour., June, 1894. in. Blow on head; Ro- landic area. 8 to 10 daily. Severe. Trephined. 3 months. 1 fit in the 3 months. EPILEPSY; INFANTILE CONVULSIONS, ETC 1097 20 Ibid. Eskridge&M'Naught, N. Y. Med. Jour., June 1, 1895. m. m. 9 34 Blow on head; frac- ture depressed. Fracture left frontal. Kick by horse. Brain extruded. Began 3 months later. Began at 19; 3 in 16 years. General convulsions; 11 on day before operation. Trephined, cyst evac- uated ; later gold- foil placed between dura and scalp. Not stated. 3 months. " Cure." No spasms since 2d operation in Aug., 1895. 22 Eskridge, Med. News, Oct. 13, 1894. f. 5 33 Blow on left parieto- frontal from fall. Began at. 15; occur daily or weekly. Right-sided convul- sions ; began in r. hand. Excision of cortex; later gold-foil used between dura and scalp. 18 months. Relapsed, but no at- tack for 1 year after 2d operation. 23 Ibid. m. 28 29 Fracture of right pa- rietal, depressed. Began 4 months later; occur 1 or 2 a week. Began in left thumb, involving left, then right, side. Trephined; 2J-inch opening. 24 years. Improved. 24 Ibid. m. 2 44 Probably pressure at birth. Began at 3 years; 2 or 3 daily. Severe. Fell on right side of face. Linear craniectomy. 4 years. Improved. 25 Angell, E., Jour. Nerv. and Ment. Dis., Oct., 1894. m. 6 Forceps-pressure (hemiplegia). Daily. General convulsions. 5 X 6.5 cm. removed over left Rolandic region. 6 months. 1 convulsion just afterward; none since. 26 Michel, M„ IF. Ala. Med. Assoc., 1892. m. 15 20 Depressed fracture of right frontal from horse-kick. 10 in 36 hours. Violent convulsions. 14-inch trephine. Os- teophyte removed. 37 years. Recurrence for 2 years; absent 35 years since. 27 Cale, G. W„ N. Y. Med. Jour., Oct. 12,1895. m. 20 26 Blow in left Rolandic region near median line. Began in 4 years. Petit mal with insan- ity. Depressed bone re- moved with tre- phine. 4 years. Cure. 28 Park, R., Med. News, Dec. 10,1892. m. 45 Comp. frac, of skull when a young man. Began in later years. Epileptic mania. Depressed bone and scar removed. 1 year. No return. 29 Keen, Am. Jour. Med. Sei., Oct., 1888. m. 23 25 Fall on right side of head. Dep. frac. Began in 6 months. Attacks of vertigo, with paralysis in left hand. Spicule of bone re- moved from brain. 4 months. No return. 30 Ibid., Sept., 1891. f. 39 Blow on left side of head in childhood. Depressed fracture. 2 in 11 yrs.; then fre- quent; 13th to 31st yr. monthly attacks. Jacksonian; right hand and arm. Same as preceding; hand-center ex- cised. 8 months. No attack. 31 Ibid. m. 7 23 Fractured skull from kick of horse. Began in 2 years. Weekly, monthly, then 4 times a year. General. Trephined and adhe- sions cut. 5 years. Attacks about once a year. In last 4 mos. once a mo. Asks another op. 32 Keen, Med. News, Apr. 12, 1890. m. 1 6 Fall at 14 months. Began at 2; had about 5000 fits. 80 per cent, began in r. hand ; others gen. Trephined; excised hand-center. 1 year. Improved. 33 Keen, private com- munication. m. 25 26 Fell 40 feet; frac, of sup. max. and right side of head. Had left hemiplegia. Began in 4 months. Six convulsions; 3 in 1 day. General, following twitching of left arm. Trephined on right side. 24 years. Paralysis is slightly better. Epilepsy not improved. 34 Ibid. m. 33 33 Fracture of skull from severe blow on vertex. Began in 5 weeks; 4 in 5 weeks. Began in left hand. Trephined. 24 years. No attacks since. 35 Ibid. m. 13 28 Fell from a horse, striking the head. 1st attack 5 yrs. later; 2d, 3 mos. later; 3d, 6 mos. later. About 2 attacks yearly. General convulsions; froths at mouth; nocturnal. Trephined on left side. 24 years. Epilepsy unim, proved, but head- aches gone. 36 Hall, R. J., Am. Jour. Med. Sci., Dec., 1895. f. 19 mos. 2| yrs. Fall on the right side of head. Began in a few hours ; 2 to 5 daily. Spasm of left arm. Osteoplastic resec- tion ; clot removed. 2 years. 1 convulsion after- ward. Improved. 1098 AN AMERICAN TEXT-BOOK OF THERAPEUTICS. No. Reporter; reference. Sex. Age at trauma. Age at opera- tion. Nature of trauma. Frequency of attacks. Nature of attacks. Operation. Under ob- servation after op'n. Result. 37 Hall, R. J., Am. Jour. Med. Sei., Dec., 1895. m. 4 26 Fall on left parietal. Began at 17. Attacks every 8 or 9 days. General. Osteoplastic resection 2 j X 2 in.; gold leaf interposed between dura and bone. 17 months. Recurrence, but im- provement. 38 Ibid. f. 3 8 Fall on left parietal. Began in 4 months; 5 to 6 daily. Jacksonian. Osteoplastic resection It X 1 in. 15 months. Unimproved. 39 Ibid. f. 10 mos. 19 mos. Hemiplegia. 5 to 25 daily. General. It inch opening. 7 months. Died unimproved. 40 Giordano, Gas. Med. de Torino, 1893, No. 43. m. 20 40 Injury to left frontal. Began at 26. Severe. Trephined. 3 years. 2 attacks in 2 mos.; none 1890 to 1893. 41 Ibid. m. 12 29 Injury to right fron- tal; no depression. Almost daily. Trephined. Recurrence. 42 Aslihurst, J., Phila. Acad. Surg., 1895. m. 14 Struck by a brickbat. Trephined. 6 weeks. Improved. 43 Kocher. m. 5 10 Fall on head. 5 or 6 daily. Right-sided. Trephined. 6 days. Died. 44 Ibid. f. 3 17 Injury to skull at birth. Began at 12; 2 or 3 daily. Trephining; cyst emp- tied. 6 months. Improved. 45 Wharton, H. R., Pres. Hospital Rec., Phila. m. 6 13 Struck with a stone on r. occip.-parietal. Began at 11; 1 to 4 monthly. Grand and petit mal. Trephined. 6 weeks. Relapse. 46 Mills & Hearn, Rob- erts' Operative Surg. of the Brain. III. 29 40 Blow on head. Began 3 years after; several hourly. Left arm, then right arm, and general. Trephined in left Ro- landic. 3 days. Died of pachymen- ingitis. 47 Porter, M. F., Med. News, Oct. 11, 1890. m. 6 Fell and wounded scalp. Began at 10; 25 to 50 daily. Right leg and thigh; Jacksonian. Trephined in left Ro- landic region. 4 months. Improved. 48 Championniere, Jour, de MM. de Paris, 1889, p. 532. m. 51 53 No trauma, but cere- bral hemorrhage. Every 2 weeks. Right hemiplegia; contracture of the hand. Clot removed from precentral convolu- tion. 4 months. No return. 49 Ricketts, B. M., Cinn. Lancet-Clinic, Nov. 9, 1895. m. 17 19 Pistol-shot of right frontal. 2 or 3 daily; began in 72 hours. Evacuated creamy fluid from cyst and removed spicule. 10 days. 1 attack 3 hours af- terward. 50 Wheeler, W. I., Trans. Roy. Acad. Med., Ire- land, vol. x., 1892. in. 36 40 Blow on right tem- poral, anteriorly. Began in 1 yr.; every 8 or 9 days. Trephined over cica- trix. Not stated. "Well." 51 Dundore, C. A., Coll, and Clin. Rec., 1889, p. 281. m. 41 42 Struck on head. Began in 3 months; 1 weekly. Right side of body; violent. Trephined. 5 months. Relapse; 4 fits after 2d operation. 52 Wilson, J. T., M. & S. Rep., 1888, p. 737. m. 39 40 Penetrating wound of skull and brain. Began in a few wks.; every 1 to 3 weeks. Severe; paralysis of left side. Trephined. 3 months. Died in fit at 3 mos. 53 Ibid. m. 23 24 Fall and fracture of left frontal. Began in 5 weeks. Severe. Treph. and removed loose piece of int. table. 5 years. Cure after 2d opera- tion. 54 Salzer, F., quoted by Gray. Injury to left side of head 4 years before. Began immediately; irregular. Right hand and arm; facial and ocular muscles. Trephined. No improvement. 55 F6re, C., L'Epilepsie. ra. Shell-wound of fron- tal bone. Began in 6 months; irregular. Attacks for 17 years. Trephined. Rough bone removed. 14 days. Unknown. EPILEPSY; INFANTILE CONVULSIONS, ETC. 1099 56 Jones, R., Liv. Med. Surg. Jour., 1889, p. 451 m. 21 23 Over left Rolandic region. Began in 1 week; ir- regular. Right-sided. Trephined over lower Rolandic. Doubtful. Whipple, Lancet, 1892, vol. 1. p. 868. m. 62* 63 Over right Rolandic Assure. Began in 4 days; 5 or 6 weekly. General; severe. Trephined. 1 month. Doubtful; no at- tacks since. 58 Hewston, F. T., Tr. Roy. Acad. Med., Ire- land, vol. x. p. 166. m. 24 30 Injury to left occiput. Began in 9 months; 3 daily. General and left- sided ; preceded by blindness. Trephined over left occiput. 10 months. No Ats. 59 Dalton, H. C., Med. Fortn'Uy, 1892, p. 75. m. 8 20 Kick by a mule in left frontal. Began in 1 month; irregular. General. Trephined. 3 years. Cure. 60 Knapp & Post, Boston Med. and Surg. Jour., Jan. 7,1891. m. 8 18 Blow on right tem- ple. Began in 1 year. Left-sided, then gen- eral. Trephined over 2d frontal convolution. 6 months. Relapse. 61 Ibid. f. 10 16 Dep. frac, over left 2d frontal convolution. General. Cortex excised. 4 months. No improvement. 62 Fisher, E. D., & Bry- ant, Starr's Brain Surgery. m. 20 34 Depression of skull over hand-center of left side. Began in 2 years. General. Trephined; found no fracture. No improvement. 63 Fisher & Woolsey, ibid. m. 22 Indehnite history. Jacksonian; sensory aura in left hand. Trephined. No improvement. 64 Fisher & Kelly, ibid. m. 33 38 Dei), of parietal be- hind motor area. Began in 1 year; daily. Trephined; dura not opened. Improvement. 65 Ibid. m. 12 26 Head-injury to left frontal from fall. Very frequent. General. Trephined. Relapse. 6.6 Diller, T„ Pittsb. Med. Rev., Nov., 1892. f. 6 mos. 11 yrs. Fall at 6 months. Began in 3J years. Began in left arm, then face and leg. Trephined; cyst drained. 43 days. Died; no Ats after operation. 67 Davis, J. D., Med. News, Nov. 9,1895. m. 20 30 Fell 15 feet; struck occiput. 2 daily; 1st attack in 1 hour. Trephined 1. occiput; enostosis removed. 3 years. Cure; no convul- sions since. 68 Ibid. m. 33 34 Blow on right parie- tal. Began in 3 months; 1 or 2 hourly. Trephined and evac. pus from cyst. 2 years. Cure. 69 Ibid. f. 20| 22 Fall on ice; struck occiput. 2 daily. Associated with vio- lent mental symp. Trephined right oc- ciput. 8 months. No return of con- vulsions. 7o Starr & McBurney, Brain Surg. by Starr. m. 161 18 Fractured left parie- tal. Began in 3 weeks. Jacksonian. Splinter of bone in mot. area removed; cyst tapped. 4 months. 2 slight attacks sub- sequently. 71 Ibid. m. 4 12i 14 Frac, over 1. coronal suture and subse- quent fall. Began in 1> yrs. after the fall; 6 daily. Jacksonian. Trephined twice and pus evacuated at 2d operation. 3 months. Relapse. 72 Ibid. in. 20 24 Fracture of middle of r. coronal suture. Began in 3 years; 2 daily. Left arm, hand, then general. Trephined over arm- center on r. side. Less than 1 year. Relapse. 73 Starr & Weir, ibid. in. 28 30 Fall on left parietal near vertex. 6 daily. Right foot, leg, then general. Trephined over upper 3u motor area for r. Died after opera- tion. 74 Starr & Hartley, ibid. in. 7 21 Frac, left parietal and frontal bones. Began after 7 years; 5 daily. General. Trephined. 5 months. Relapse. 75 Starr and Poore, ibid. f. 2i 3 Fall on right parietal. Began in 3 months; 7 daily. Spasms of left arm. Evacuated cyst with- out trephine. 1 year. Relapse. 76 Starr and Briddon, ibid. m. 37 40 Fractured r. temple. Irregular; began in 1 year. At Arst general, then in right face, neck, arm, and hand. Trephined over Bro- ca's convolution. 4 months Relapse. 1100 AN AMERICAN TEXT-BOOK OF THERAPEUTICS. No. Reporter; reference. Sex. 1 Age at trauma. Age at opera- tion. 1 Nature of trauma. Frequency of attacks. Nature of attacks, j Operation. Under ob- servation after op'n. Result. 77 Starr & McBurney, m. 29 30 Struck with sand-bag Began in 3 months. Jacksonian. Treph. over cent, for 6 months. Relapse; death in Brain Surg. by Starr. on left side of head. arm, face, & speech. 17 months. 78 Ibid. m. 2 12 Fall on head. Began at once. Right-sided; affect- Trephined over arm- 3 months. Return of petit mat. ing eyes and head. center. 79 Ibid. m. 18 23 Fall on vertex. Began soon after. General. Trephined. 4 months. 5 attacks in 4 mos. 80 Ibid. in. 9 11 Fall on left parietal. Began soon after; 6 Jacksonian; r. hand, Trephined. 1 year. Relapsed, but im- in one night. ling., th'mb, & arm. proved later. 81 Ibid. in. 50 Fall, sev. yrs. before. Began in right hand. Trephined twice. H years. Relapse. 82 Ibid. in 9 32 Fracture of left parie- Began at 23; 5 daily. General. 2X3 in. trephined. 21 years. Relapse. tai from fall. 83 Starr & Park, Intern'I m. ad. 6 years previously, Fits began 6 weeks Jacksonian; began in Trephined 2X11 in. 5 years. Relapse. Clinics, voL iv., 3d injury to posterior after fall; 3 weeks' right hand. over center for series. portion of parietal. interval. right hand. 84 Starr, M. A., ibid. in. 9 11 Fractured skull, an- Had a severe illness Jacksonian. Cyst evacuated. 2 years. Relapse. terior vertex. and hemiplegia; 7 attacks daily. 85 Ibid. ad. Front, and r. parietal 1 in 2 or 3 weeks. Jacksonian. Cortex excised. 3 weeks. Doubtful. frac. 4 yrs. prev. 86 Parker & Gotch, Brit. m. 8 9 Fall on right side of 3 weeks later tremor Jacksonian. Centers for thumb 5 months. Relapse. Med. Jour., May 27, head. in left hand; many and wrist excised. 1893. attacks daily. 87 Kocher, Zeit. f. Chir., m. 12 40 Pistol-shot wound of Began 4 weeks later. Jacksonian. Excision centers for 3 weeks. Died of dural tumor. 1893, xxvi. little finger 1. hand. 1. hand and lit. fin. Fits recurred. 88 Ibid. m. 29 38 Injury to left motor Began li yrs. later in Jacksonian. Trephined. 5 months. Relapse. area. r. hand. Every 2 or 3 days. 89 Ibid. m. 16 24 Depressed frac, skull Began in 6 weeks; Jacksonian; r. arm 8X5 cm. of skull re- 7 years. Relapse. from fall. several daily. and leg. moved. 90 Ibid. m. 6i 81 Depressed frac, skull Began in 2 years. Jacksonian. Trephined; excised 10 months. No attacks. from fall. cortex. 91 Ibid. m. 3 15 Fall. Began at 13; 3 or 4 Jacksonian. Scar and dura exci'd; 2 months. No attacks. daily. opening enlarged. 92 Ibid. m. 13 14 Frac, skull along me- Began in 7 months; Severe, left-sided. Trephined along the 3 months. Unimproved. dian line. 2 to 4 daily. longitudinal sinus. 93 m. 12 20 Injury to occiput. Jacksonian. Trephined. 1 year. No improvement. 94 in. 1* 16 Fall from window. Left-sided and gen'l. Trephined. 1 year. No improvement. 95 m. 30 Injured r. parietal. General. Trephined occiput. 5 months. No improvement. 96 Gerster & Sachs, ill. 7 mos. 8 General. Trephined mastoid. 1 year. Great improvement. 97 .'I //o'/ lain Ji/UI nal of the Medical ■ Sciences, Nov., 111. in 26 Kicked on r. occiput. Trephined and re- moved exostosis. 1 month. Relapse. 98 1892. 8 cases. m. 18 24 Fall on right occiput. 6 daily. Jacksonian. Removed arm-center. 6 months. Relapse. 99 f. 6 mos. 9 Fall out of bed. 50 daily. Trephined. 8 months. | Slight improvem'nt. 100 1 m. 1 10 1 12 , Fall on back of head. I Frequent. Trephined. 1 6 months. EPILEPSY; INFANTILE CONVULSIONS, ETC. 1101 101 Lloyd & Deaver, Brooklyn Med. Jour., Oct., 1893. m. 28 1st attack at 17. 8 to 25 every 24 hours. Aura in left arm; Jacksonian. Trephined over right motor region, 2 in. X U in. 5 years. Cessation for 7 mos. Relapse. 102 Barber, C. F., ibid. f. 8 Since childhood. 1 to 20 daily. Aura in 1. arm ; con- vulsions violent. Trephined over right 6 years. Cessation for 1 wk. arm-center. Relapse. 103 Angell, N. Y. Med. m. 13 Began at 3J. Several daily; status Began in r. thumb, Excision of arm-cen- 24 days. Death. Jour., Apr. 18,1891. epilepticus. for'arm, shoul., face. ter. 104 Morrison, W., Phila. Co. Med. Soc., 1892. m. Began at 2. Daily. General; grand and petit mal. I in. X 2 in. trephined. 5 years. Relapse. 105 Lloyd & Deaver, Int'l m. 45 Began at 45. Frequent. Jacksonian; began in Excision of center Relapse. Clinic*, vol. iii. 2d r. great toe, becom- for r. arm and foot. series. ing general. 106 Gerster & Sachs, Am. J. M. Sci., Nov., 1892. m. 6 Began at 5|. Right-sided convul- sions. Trephined. 1 month. Relapse. 107 Ibid. m. 9 Began at 7 or 8. Jacksonian. Excision of center Relapse. for right hand. 108 Shaw, A. B., ibid., f. 31 Began at 30. 30 in 3 weeks. Jacksonian and gen- Trephined and osteo- 7 months. No return. Dec., 1892. eral convulsions. phyte removed. 109 Mills & Keen, Am. J.M. Sci., Dec., 1891. f. 27 Began at 17. 6 or 7 daily. Jacksonian. Cortex excised; sar- 7 months. Relapse. coma removed. 110 Crowley, D. D., Occid'l f. 26 Began in childhood; One monthly. Not stated. Trephined near pa- 3 months. No attack; improv'd Med. Times, 1894, p. memory impaired; rietal eminence, 1. mentally. 122. speech defective. side. 111 Fisher & Kelly, Starr's f. 20 Began in childhood. 100 daily. Left-sided. Arm-center excised. Died in 6 hours. Brain Surgery. 112 Stieglitz, L., M. News, f. ad. 3 or 4 monthly. Jacksonian; r. arm, 2 operations; remov'd 6 months. No return. Nov. 2, 1895. face, then general. arm-center. 113 Ricketts, B. M., Cinn. m. 8 Began at 2. Frequent. Severe. Trephined; cireum- 2 months. One convulsion; Lancet-Clinic, Nov. 9,1895. cised; hernia cut. died of poison. 114 Ibid. m. 14 General convulsions, Double craniectomy. 4 months. Relapse. severe. 115 Kappeler, Deuts. Zeit. m. 43 Jacksonian. Endothelioma rem'd Entirely relieved. f. Chirurgie, Nos. 5 from upper Rolan- and 6, p. 500. die area. 116 Packard, J. H., per- m. 14 General convulsions. Trephined 3 times; 4 years. Improvement, then sonal communica- both parietal re- relapse; died in tion. gions opened. convulsion. 117 Keen, Orthopedic Hos- m. 53 Convulsions in left Trephined over el- 6 months. Died; tuberculous 118 pital Records. arm. bow-center. growth found. Keen, private com- f. 21 1st attack in 1888 ; 2d Before operat'n were Jacksonian; began in Trephined. 4 years. Attacks about once munieation. in 1889; later, more almost daily, oeca- right thumb, then in a year or a lit- 119 Ibid. frequent. sionally twice a day. general. tie less. f. 9 No aura; uncon- As many as 7 daily, Right side affected; Trephined. 2 years. Unimproved. 120 Hall, Am. Jour. Med. Sci., Dec., 1895. scious. lasting 1 to 5 min. bites tongue. f. 21 Began at 3; idiotic. 1 to 60 daily. General. 21 X H in. opening. 1 month. Died unimproved. 121 Ibid. f. 2 Began at 10 months ; 1 to 3 nightly. Linear craniectomy. 6 months. Improved. idiotic.