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Professor of Diseases of Children, Philadelphia Polyclinic ; Neurologist to Howard 
Hospital; Assistant Physician Orthopedic Hospital, and to the 
Children’s Hospital, etc., etc. 

I T may be interesting to see and examine a case of 
epilepsy operated upon with such absolute success. 
This boy, or rather young man, I reported five 
years ago . 2 It occurred in the service of Dr. Weir 
Mitchell, and the operation was performed by Dr. T. G. 
Morton in the Orthopaedic Hospital. The early history 
in brief was this: W. B., a perfectly healthy boy, of 
wholesome antecedents, fell at the age of two years and 
eleven months a distance of fifteen or eighteen feet, 
fracturing his skull over the right parietal prominence; 
no convulsion at the time, and the wound promptly 
healed. Soon after there began occasional slight spasms, 
beginning with an aura, starting up the left forefinger 
and thumb, and limited to the arm. Later these in¬ 
creased, and a fuller description from the young man 
himself differs somewhat from the earlier notes, but is 
probably accurate because he is intelligent and quite 
positive on the subject. These smaller spasms the par¬ 
ents considered outgrown, and ended for a year or two. 
The first general convulsion occurred at the age of about 
ten years while in school, being rather excited over an 
unusual effort in arithmetic. While working very hard 
to accomplish the task, he noticed a greatly increased 
activity in the spasmodic opening and closing of the left 
forefinger and thumb, a phenomenon observed before, 
but held of small account. Presently the whole hand 
stiffened, the fingers clenched, the wrist flexed violently 
upon the arm, the arm flexed at the elbow, and was car¬ 
ried forcibly up under the axilla; the left side of the 
mouth was drawn down, then the left leg became some- 

'Case exhibited at the Philadelphia Neurological Society, December 
17, 1894. 

8 Ann Gyn. and Paediatry, August, 1890. 



what like the arm, and finally he fell. Other attacks, 
usually superinduced by some mental or emotional ex¬ 
citement, occurred like this once or twice a month. The 
aura gave from a minute to a minute and a half warning, 
and the attacks could often be successfully controlled by 
a powerful effort on the patient’s part or that of his par¬ 
ents to unlock the contractured parts persistently with 
the right hand, and to rub the palm vigorously. After 
the convulsions, during the period in which they were 
most severe, both the arm and leg were entirely para¬ 
lyzed as to motion and sensation for an hour or two, then 
rapidly recovered. The boy was conscious throughout 
the seizure. He could hear and see plainly, yet was un¬ 
able to move or speak, soon becoming vividly conscious 
of the absence of the arm and leg as the paralysis grew 
complete, and he would habitually ask to have the dam¬ 
aged arm placed in the sound hand so as to assure him¬ 
self of its presence. When in the progress of the seiz 
ure the inevitable fall was about to occur the lad was 
always able to guide himself in a way so as to avoid 
receiving undue damages, and to especially protect the 
tender spot in the head by partly adjusting himself. 
If he were to lie on the right side the convulsions 
would continue, and it was necessary that he should 
be turned on his left for it to cease. Cold water or 
ice applied to the tender spot had the effcet of limit¬ 
ing the convulsion. 

Examination of the lesion, December 12, 1886 (this 
was before the crytometer had come into use), showed ab¬ 
sence of bone over an irregular area (see diagram which 
I made at the time of the first examination) about two 
and one-half inches long vertically, starting two inches 
behind and in a horizontal line with the top of the ex¬ 
ternal meatus of the right ear, and extending to within 
an inch of the vertex. The opening at its greatest 
width above the middle line was about one and three- 
quarter inches. On the posterior edge of the opening 
was a pointed mass of bone, elastic to the touch, pressure 
upon which produced a most sickening pain, and if con¬ 
tinued induced a severe general convulsion. Also at that 
time the left hand and arm were of lessened develop¬ 
ment and vigor ; not so the leg; knee-jerk excessive on 
both sides ; station good ; heart perfectly sound. 

Examination of the eyes by Dr. George de Schwein- 
itz showed the following: 

Vision, each eye.—Amplitude of accommodation 



diminished 3 0 . Reflex and associated movements of the 
iris normal. No muscular anomalies, except insuffi¬ 
ciency of the internal recti of 6°. 

Ophthalmoscope.—Right eye : Round nerve healthy 
color. Slight absorbing conus, outer side. Along the 
nasal artery small black spots, the questionable remains 
of haemorrhage. Refraction H. Left eye normal, nat¬ 
ural color ; blotchy pigment conus at outer side ; veins 
somewhat tortuous; macula normal. Refraction H. 
Central color perception good ; fields of vision for form 
and color normal. 

Diagnosis.—Hypermetropia and slight astigmatism, 
with insufficiency of internal recti. No appearance in 
fundus not explained by this error of refraction. 

Operation March, i 887.<—Dr. Morton, on lifting the 
scalp, found no spicules of bone projecting into the 
brain, but owing to the irregularities of the edges of the 
bony opening, certain pointed masses pressed severely 
upon the cortical substance. These acted as obvious 
causes for the convulsions, and they were carefully 
trimmed away, not disturbing the dura. No bone was 
replaced the scalp was carefully readjusted. The recov¬ 
ery was uninterrupted and rapid. 

Description of W. B., December 17, 1894, as exhibited 
to the Philadelphia Neurological Society: Aged twenty- 
one and a half years, height five feet seven, weight one 
hundred and thirty-five; has enjoyed perfectly good 
health since the operation; is a powerful, muscular 
mechanic, earning an excellent livelihood as an artistic 
tile-setter. There has been no convulsion, except pos¬ 
sibly a partial one soon after the operation, on which 
point is some doubt. The opening in the skull is still 
about as large as described in 1890. This is a depressed 
area, pulsating regularly, varying in depth in accord¬ 
ance with trifling disturbances of health. He very rarely 
has headaches, and only when touched or struck on this 
spot; then the pain is localized there. No considerable 
blow has been received, except one about two months 
ago. A companion playfully threw a soaked paper ball 
the size of an orange, striking him fairly on the tender 
place. Falling instantly to the floor, he suffered for 
some hours thereafter intense pain. The left arm is 
about three-eighths of an inch less in length than the 
right; but the chief difference resides in the hand, the left 
being fully a half inch shorter than the right, and the 
whole member proportionately small. The legs seem 



precisely similar; the buttock lines are symmetrical; 
the left foot is smaller than the right, but no more, per¬ 
haps, than is natural. 

The points of special interest here are: First, the 
entire relief to the convulsions. Second, perfect recov¬ 
ery of functional activity of the limbs. Third, entire 
absence of spasticity or other damage to the motor tracts 
except only the lessened development of the one arm 
and hand which is confined to size and not modifying 
strength to any considerable extent. Fourth, perfect 
co-ordination, normal growth and development of intel¬ 

The Therapeutic Utility of Trional.—'Dx. B. Rohmer. In¬ 
augural Dissertation presented to the University of Strassburg, 1894. 
The remedy was employed in twenty-nine cases in which sleep, was dis¬ 
turbed by restlessness, bodily pains or irritating cough. In ali but one 
case trional was found to possess hypnotic properties, and in twelve of 
these the effect was always the same, although the period of administra¬ 
tion extended over several weeks. In seven cases the effect was weak¬ 
ened or lost in the course of time, necessitating an increase of dose. In 
some cases the apparent cause of this was the presence of bodily pains 
which exerted an inhabitory influence upon the action of Trional. Thus, 
in a case where sleep of ten hours’ duration resulted from the 15 grains 
given the first evening, the effect of the same dose given on the follow¬ 
ing day was completely counteracted by the presence of toothache. 
That the pain must, however, attain a more or less high degree of in¬ 
tensity in order to neutralize the action of the remedy is demonstrated 
by a case of tabes dorsalis in which sleep could not be induced by 
morphine, but followed administration of one-half drachm trional. 
The author’s experience further demonstrates that the action of a single 
dose may extend over several nights, although he was unable to confirm 
the observations of others that the effect is developed on the average in 
the course of half an hour. Even in the case where its action was pro¬ 
nounced, sleep frequently failed to appear until the end of tw r o hours. 
The duration of the effect varied from two and one-half to ten hours. 
Sleep was deep and quiet and the patients rarely experienced any dis¬ 
turbances on waking. Judging from its behavior in two cases of cardiac 
disease, trional seems to be devoid of tonic influence upon the circula¬ 
tory system. After prolonged administration no disturbances resulted 
when it was discontinued. Rohmer’s observations conform, therefore, 
in the main to the experience of other observers. He regards the 
remedy as especially indicated in psychiatric practice, and recommends 
its use in simple insomnia and even where this condition is due to pain. 
The doses varied from a ha f to two scruples given in wafers. J. C.