Jacksonian Epilepsy; Trephining; Removal 
of Small Tumor and Excision of 
Cortex. 
BY 
CHARLES K. MILLS, M.D., 
NEUROLOGIST TO THE PHILADELPHIA HOLPITAL, ETC., 
AND 
W. W. KEEN, M.D., 
PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
December, 1891. Extracted from 
The American Journal of the Medical Sciences for December, 1891. 
JACKSONIAN EPILEPSY; TREPHINING; REMOVAL OF SMALL 
TUMOR, AND EXCISION OF CORTEX. 
By Charles K. Mills, M.D., 
NEUROLOGIST TO THE PHILADELPHIA HOSPITAL, ETC., 
AND 
W. W. Keen, M.D., 
PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL 
S. W., female, twenty-seven years old ; height, five feet; weight, niuety- 
eight pounds. Until the first symptoms of the spasmodic affection for 
which she applied for treatment she had been in excellent health, with 
the exception of an attack of chronic otitis when a child, which had 
left her with a perforated membrana tympani and the occasional recur- 
rence of a slight discharge. Ten years before coming under observation, 
while in a cold room in the northwest, she had for the first time a slight 
attack of left hemiparsesthesia; her left hand, arm, and foot became 
numb and heavy. The sensation passed off in a few moments and was 
not accompanied by spasm or vertigo; but from this time, at intervals 
of weeks or months, she had attacks, usually slight, of the same char- 
acter. Handling or unusual movements of the left arm would some- 
times bring them on ; at other times they would come on without any 
apparent exciting cause. Between four and five years after the first of 
these sensory seizures, she had for the first time, as an accompaniment, a 
spasm involving both the left upper and lower extremity, but more 
marked in the former. From this time on she had at irregular, but 
more frequent intervals, these sensory and motor attacks, the spasm be- 
ginning on the left side, but after a time markedly attacking the right 
arm as well. The seizures increased in frequency, until after a few 
months she had them almost every day, and often six or seven during 
the twenty-four hours. The only time when she was free from them for 
a long period was in the spring of 1890, when, while suffering with a 
fever, she had no attacks for about three weeks. Although the attacks 
increased in severity and frequency, they had for many months remained 
much the same as they were when she first came under observation. She 
had been treated by various physicians, and on several occasions bromide 
treatment had been pushed, but always without any improvement, and 
usually she thought she grew worse under the use of drugs. She was 
sent to me for diagnosis and treatment by Dr. H. C. Yarrow, of Wash- 
ington, D. C. Her general health, mental and physical, was good, and 
she had no evidence of paralysis. 
Soon after coming under observation I had several opportunities of 
witnessing her seizures, and one description would answer for all, with 
the exception that sometimes her consciousness was more deeply affected 
Medical History by Dr. Mills. 2 
MILLS, KEEN, JACKSONIAN EPILEPSY. 
than at others. She would feel a prickling sensation in her left arm, and 
would utter a plaintive cry. The left arm would immediately extend at 
the shoulder and elbow, and almost coincidently the left leg would be- 
come spastic in extension, and the head would be twisted to the right. 
The right upper extremity would then be strongly flexed at the elbow, 
and the whole limb carried over the chest, as if the hand was grasping at 
the precordial region. The spasm continued for a few seconds, passing 
off with a laughing sound and facial expression. In the shortest attacks 
she did not appear to lose consciousness at all, and during the early 
weeks that she remained under observation she never seemed to be com- 
pletely unconscious during the seizures, and could detail most of what 
was said and done by others during them. She sometimes complained 
of having pain in the precordial region. She repelled any touching or 
handling during the spells, and explained afterward that it hurt her and 
made her worse. 
At first the case was regarded as probably one of hystero-epilepsy, and 
the patient was treated with tonics and gymnastics to improve her gen- 
eral and nervous health, but in spite of such treatment and the best of 
care her attacks grew more frequent and severe. About three months 
after coming under observation, an attack, which began in the usual 
manner, became extremely violent, and was attended with total uncon- 
sciousness. In November the patient began to have day and night as 
many as ten to fifteen serious attacks. After several consultations with 
Drs. Mitchell, Keen, Sinkler and Lloyd, it was finally decided that an 
operation should be performed. 
In deciding on a site for operation the history and character of the 
sensory and spasmodic attacks were carefully considered. The case had 
begun with sensory disturbance in the limbs of the left side, particularly 
in the upper extremity. The spasm had first affected this side, and 
usually', as nearly as could be determined, was initiated with a shoulder 
movement on this side, although the spasm diffused and extended so 
rapidly to all parts of the left arm and leg, and to the right upper ex- 
tremity, that it was sometimes difficult to determine how it began. 
Sometimes, however, the right side escaped. On the left side the patient 
showed slight drooping and apparent weakness of the muscles about the 
mouth, although this was so little marked as to be scarcely more than 
is not infrequently present normally. 
Operation was performed December 10, 1890, by Dr. W. W. Keen. 
The following were present at the operation : Dr. Roswell Park, of Buf- 
falo ; Dr. Raphael Lorini, of Washington ; Drs. W. J. Taylor, Whar- 
ton Sinkler, J. H. Lloyd, F. X. Dercum, J. B. Deaver, De F. Willard, 
M. I. Bassette, and J. W. McConnell. 
On the day preceding the operation Dr. Bassette examined the patient 
and made the following report of her condition : Pupils normal; slight 
drooping of the left upper lip, but otherwise the face normal; no paral- 
ysis of the limbs; no impairment of touch, sight, taste, or smell. Hear- 
ing much impaired on the left side. Dr. C. S. Turnbull had previously 
examined her ears, and had reported a chronic otitis media with per- 
foration, which required but little treatment, and which he thought had 
nothing to do with her brain symptoms. Knee-jerk was present; no 
ankle clonus. Heart and lungs were normal. MILLS, KEEN, JACKSONIAN EPILEPSY. 
3 
Surgical History and Remarks by Dr. Keen. 
On the day before the operation the carpet was taken up, the walls 
wiped down, and the floor, woodwork, etc., were washed with a solution 
of carbolic acid, 1 to 40. The patient’s head was shaved and carefully 
disinfected. The position of the fissure of Ilolando was outlined first by 
means of Hare’s method, and then by that of Horsley, the cranial index 
being determined from measurements made as follows: 
Antero-posterior diameter 19.1 cm.; biparietal diameter 14.3 cm. 
14.3 h- 19.1 = 0.748 +. Practically the cranial index was therefore 
0.75 ; and this corresponded to an angle of 69° for the Rolandic fissure. 
From glabella to inion was 13.25. 
The position for the trephine centre was fixed 1.75 inch to the right 
of the median line, in the line of the fissure of Rolando and was 
marked on the scalp by a small puncture in the bone. The fissure of 
Rolando was also marked at its two extremities by two similar punc- 
tures in the bone, so as to identify it after its surface marking was lost 
by the lifting of the Hap. 
A large horseshoe flap was made, and on turning this back no abnor- 
mal appearances of the skull were found. The centre pin of a 1J inch 
trephine was now inserted 1.75 inch from the median line as before 
determined, the upper edge of the trephine reaching to a point 1 inch 
from the median line. 
Dr. Roswell Park kindly did the trephining for me, so that my 
hands should not be unsteadied by the muscular fatigue involved in this 
part of the operation. It was very fortunate that I asked him to do so, 
for the skull was very thick and the trephining required time and a good 
deal of muscular effort. The thickness of the button removed varied 
from T% inch to inch, and the diploe was almost entirely obliterated. 
Fig. 1. 
The button of bone removed, showing its thickness and the erosion caused by the 
tumor of the dura and the vessel supplying it. 
The under surface of the button of bone was eroded in a number of con- 
nected small pits corresponding to the small growth described below 
The little pits resembled a miniature bunch of grapes, the stem of the 
bunch consisting of a vessel of considerable size which had also eroded 
the bone. On the removal of the button of bone, free hemorrhage took 
place from the dura at the margin of the trephine opening where this 
vessel ran, but the bleeding was soon controlled by a ligature. The tip 4 
MILLS, KEEN, JACKSONIAN EPILEPSY. 
of the growth was y inch in front of, and the same distance internal 
to the centre of the trephine opening. The growth was elevated \ inch 
above the surface of the dura, and after cutting the dura and lifting the 
flap, it was found that the granulation or growth had its origin appar- 
ently from the pia, and had bored through the dura and formed a nest 
for itself in the skull. The dura and the pia were adherent at the point 
where the growth lay. 
A triangular bit of the dura, including the growth, was removed by 
the scissors and placed in Muller’s fluid. The exposed pia-arachnoid 
was oedematous with enlarged veins and capillaries. Nothing else 
abnormal was found. A fissure corresponding to the line of the fissure 
of Rolando was seen, and five convolutions were exposed, all of which 
appeared to be normal. (See Fig. 2.) From the moment that the brain 
was exposed no antiseptics were applied to it, but only warm, boiled 
water. 
Careful investigations were then made with the faradic current with a 
view of determining the cortical centres exposed. A small bipolar anti- 
septic electrode was used. A secondary current was applied ; the elec- 
trode was connected with the terminal of a Flemming faradic battery, 
and the current was obtained by passing the switch to the first button of 
the instrument, and withdrawing the regulating cylinder to a distance 
of 2y inches. 
Several spots were selected, marked 1, 2, 3, and 4 (see Fig. 2). The 
first electric tests were made at the spots 1 and 2. From the measure- 
ments that had been made, the fissure of Rolando was in the direction 
indicated by the line seen in the illustration. 
Electricity was first applied to the spot marked 1 for a moment only. 
Movement at once resulted, beginning in the upper extremity on the 
left side, the first movement being protraction and moderate adduction 
of the shoulder and upper arm. This was followed by a series of jerks, 
involving the upper, and to a more moderate degree, the lower arm. 
No differentiated movements of the hand and arm, and no face or upper 
leg contractions, were observed. The left toes and foot, however, slightly 
flexed coincidently with the shoulder movement. 
A second application was made at the point marked 2. The effect of 
this excitation was again to produce decided shoulder and arm move- 
ments, with greater adduction and some protraction of the entire arm. 
The thigh was flexed upon the pelvis at an angle of about 130°, and 
the leg upon the thigh to about the same, with abduction of the thigh 
and extension of the toes and foot. At the same time, active, coarse, 
clonic movements diffused through both extremities. This series of 
movements of the left upper and lower extremities strongly resembled 
the spasms which occurred in the patient’s ordinary attacks, with the 
exception that the head was not turned to the right, and no face move- 
ments were noted. The application was repeated at 2, with similar re- 
sults, with the addition that the face and head turned to the left, and 
the head was drawn downward and to the left, chiefly by platysmic 
action. 
The electrical tests clearly indicated that the centres for the shoulder, 
upper arm, thigh and knee had been determined, or probably the region 
which represents the merging of the movements of the upper and lower 
extremities. A consultation was held with reference to the propriety of 
excising this region, and it was determined to do this, first, in order to MILLS, KEEN, JACKSONIAN EPILEPSY. 
make a sub-cortical exploration for any further lesion, and secondly, to 
prevent the recurrence of the spasms by removing what seemed to be 
their primary seat. 
With a pair of scissors and sharp bistoury a portion of the cortex, 
three-quarters of an inch in diameter, was removed. It included all the 
cortical gray matter under the tumor and corresponding to the centre 
for the shoulder as ascertained by the battery. The arm, leg and face 
were carefully observed during excision, but this mechanical excitation 
was absolutely without effect in producing movements. 
Fig. 2. 
After excision the electrodes were now applied to the points 3 and 4 
on the border of the excision. 
Excitation at the point marked 3 flexed the elbow, hand and wrist 
with slight shoulder abduction, protraction closely following. 
Excitation at 4 caused primary movements of abduction and flexion 
of the thigh upon the pelvis, and the leg upon the thigh at an angle of 
135° or 140°. No foot movements or movements of the upper ex- 
tremities occurred. In all the trials after the excision of the cortex the 
movements were confined to the left half of the body. 
After the excision had been performed considerable trouble arose in 
checking the hemorrhage from a large vessel, but this was controlled by 
two ligatures passed into the brain, and by temporary packing with 
iodoform gauze. During the operation small bits of iodoform gauze 
were packed between the dura and the skull to check some hemorrhage. 
The pulse fluctuated markedly, becoming for a short time weak and 
rapid. The extremities also became cold. The hemorrhage having 
been checked by pressure and hot water, after the ligature referred to 6 
MILLS, KEEN, JACKSONIAN EPILEPSY. 
had been applied, a small rubber drainage-tube was inserted through 
the defect in the dura. A small bundle of horsehairs was also passed 
through and through under the flap, which was then sutured into place 
and dressed as usual. The bone was not replaced, as this was not deemed 
wise in consequence of its thickness and its sclerosed condition. 
On December 11th, the first day after the operation, the drainage- 
tube was removed. On the 13th, the third day, the horsehair was re- 
moved, and a slight escape of cerebro-spinal fluid occurred. On the 
15th, the fifth day, nine stitches were taken out and five were left. On 
the 21st, the eleventh day, the last stitches were removed from the 
wound, which was entirely healed except at one or two of the stitch- 
holes and where the flap was at a slightly different level. 
Temperature record for ten days after operation.—December 10. 4.40 
p.m., 96.6° ; 8 p.m., 100.6°. 
11 th (first day after 
operation) 
8 a.m., 99.8° ; 4 p.m, 99.4° ; 8 p.m., 100.2°. 
12tli (second day) “ 100.2° “ 100.4° “ 100.2°. 
13th (third day). “ 99.2U “ 99.4° “ 99.4°. 
14th (fourth day) “ 100.6° “ 99.2° “ 99.2°. 
15th (fifth day) “ 98.4° “ 99.2° “ 99.4°. 
16th (sixth day) “ 98.4° “ 98.8° “ 98.6°. 
17th (seventh day) “ 98° “ 98.8° “ 99.2°. 
18th (eighth day) “ 98° “ 98.8° “ 98.6°. 
19th (ninth day) “ 97.6° “ 99° “ 98.6°. 
20th (tenth day) “ 97° “ 98.6° “ 98.8°. 
Remarks.—The bone was so much thickened and sclerosed as to raise 
the question whether there was not possibly an element of hereditary 
syphilis in the case, but this it was learned could be positively excluded. 
In the absence of such an explanation it was, of course, possible that the 
thickening of the bone was due to the irritation caused by the pressure 
of the little growth. Whether it was only a local thickening could not 
be accurately ascertained at the operation. In either case it seemed 
unwise to replace the bone. 
Accuracy of localization. The accuracy of the localization of the 
shoulder centre and also of the centres in its neighborhood is worthy of 
remark. The tip of the growth was found within one-sixteenth of an 
inch of the point selected as the location of the shoulder centre and the 
probable seat of the irritation. 
The nature of the growth. Its appearance suggested that it was a 
hypertrophied- pacchyonian body, but the microscopical examination 
showed that it was sarcomatous, with some hemorrhagic pachymenin- 
gitis. That it was the probable cause of the epileptic attacks seems very 
reasonable. Unfortunately, the irritation had possibly continued long 
enough to establish the epileptic habit, and to this may be due the fact 
that the attacks have continued since the operation, though with less- 
ened frequency and severity; or, as suggested by Dr. Mills, sarcomatous 
growths or infiltration may be present elsewhere in the brain. Whether MILLS, KEEN, JACKSONIAN EPILEPSY. 
the attacks will ultimately disappear or not is a question which we are 
not yet in a position to decide. 
Excision of the cortex. The operation might have been limited to the 
removal of the growth and the dura which contained it, and then later, 
had the attacks not disappeared, a second operation might have been 
done and the shoulder centre removed. Against this, however, is the 
argument that a second operation involves a second peril to life, and 
also that the convolutions might be so adherent to the flap and the new 
tissue which would fill the opening, that it might be difficult at the 
second operation to recognize them, and to delimit the centres to be 
removed with the same accuracy that we could at the primary opera- 
tion. All the questions which present themselves on reflection upon 
such cases should be stated with a viewr to their consideration, and the 
determination of what is the wisest course. 
Drainage. Since this operation was done I have operated on a num- 
ber of cerebral cases, with absolute closure of the wound without drain- 
age. In two cases there has been considerable accumulation of bloody 
serum which has been evacuated by gentle separation of the flap between 
the sutures. In one case this had to be done four times, and in the other 
but once; so that I am now quite convinced that, as a rule, drainage 
can be dispensed with in cerebral operations. Had it been dispensed 
with in this case the apparent risk of a fungus cerebri would have been 
avoided. In fact, I think this one of the strongest reasons why drain- 
age should not be employed in cerebral cases. Possibly a few strands 
of horsehair might be used to advantage for twenty-four hours, but a 
drainage-tube should not be used. 
After removal of the dura, cannot the loss of substance be made good by 
the transplantation of a piece of the pericranium t In the after-history 
of the case one point was purposely not mentioned, but reserved for con- 
sideration here. A few days after the operation the flap bulged to such 
an extent that I was afraid that the union of the flap to the rest of the 
scalp would give way, and that a fungus cerebri would appear, especially 
at the site of the drainage-tube. Fortunately, this did not occur, but the 
bulging gradually subsided and the wound healed without incident. In 
reflecting upon this case, it occurred to me that the conditions were 
most favorable for the formation, almost inevitably, of a fungus cerebri, 
which I believe actually took place subcutaneously, but fortunately 
subsided without appearing on the surface. Under the flap was a deep 
well, corresponding to the thickened bone, the dura, and the excised 
portion of the brain; in depth perhaps an inch or more. 
When the dura is opened and closed by suture there is little danger 
of a fungus cerebri, but where there is a loss of substance of the dura, 
and especially where the cortex is excised, there is a marked tendency 
to the formation of a fungus cerebri, especially where the distance be- 8 
MILLS, KEEN, JACKSONIAN EPILEPSY. 
tween the scalp and the surface of the excised portion of the brain is as 
deep as in this case. To avoid this it occurred to me that we had ready 
means at hand in the transplantation of a piece of the pericranium 
similar to the transplantation of skin by Thiersch’s method. 
On the 10th of May, 1891, in another case operated upon at the Jef- 
ferson College Hospital, an opportunity occurred to me to test this. A 
piece of the pericranium was separated from the scalp, cut loose, and 
attached by a few interrupted sutures at its margin to the dura, thus 
filling the gap produced by the excision of a piece of the dura. The 
transplanted bit was turned upside down, so that the osteogenetic surface 
lay upward, in order that if bone should form from it, it should grow 
upward into the gap in the skull, rather than downward, and so possibly 
press upon the brain. The result was all that I could wish. No fungus 
cerebri formed, and up to September 1st he had not only been entirely 
free from his epileptic attacks, but no mischief had arisen from the 
transplanted pericranium, which presumably therefore has retained its 
vitality. 
Can we differentiate normal from apparently normal, yet, in fact, diseased 
cortex, by means of the battery f This question I cannot yet answer posi- 
tively, but I am inclined to think that it may be answered possibly in 
the affirmative. If we faradize a normal cortical centre (motor) by a 
single application, for a moment we get response in a single motor ex- 
pression of its function, and the muscles cease to respond the moment 
the electrodes are removed. In several cases of visibly diseased cortex, 
by a similar single and short application of the electrodes, I have evoked 
not a single motor response, but have started an epileptic fit, resembling 
in the part in which it started and in its march the fits from which the 
patient had suffered. After excision of the diseased cortex similar brief 
stimulation has produced only the normal single motor response. It 
may be that this is explained by the fact that the first stimulation was 
of gray matter, and the last of white matter after the excision of the 
former. In some cases in which I have operated on the brain after 
injury and loss of brain-substance, presumably cortical (chiefly so, at 
least), faradization of the diseased and disintegrated brain-substance, 
presumably chiefly white matter, has started the characteristic fit, and, 
after excision, faradization of the underlying apparently normal matter 
has again given me a single normal response. If, then, faradization of 
apparently normal cortex induces a typical epileptic fit, instead of a 
single motor response, can we conclude that, though normal to the eye 
and finger, it is really diseased and should be excised ? If so, this will 
be a most important and valuable aid to us. 
My observations on this point are yet too few to warrant a definite 
conclusion. MILLS, KEEN, JACKSONIAN EPILEPSY. 
Medical History After the Operation, and Certain Special 
Features of the Case, by Dr. Mills. 
History of loss and recovery of poiver in the left limbs after the operation; 
sensory investigation. When the patient came to from the effects of the 
ether, she had a feeling of numbness and heaviness in the left arm and 
hand, and also at times in the back of the left shoulder—what she de- 
scribed as a “ battery sensation,” or a feeling of prickling. Five hours 
after the completion of the operation she was cautiously tested for motion 
and sensation. The tests were not elaborate, for fear of disturbing her 
too much. The left shoulder movements were paralyzed, but all the 
forearm, hand, and finger movements were retained, but weak. The 
power of flexion at the elbow was very feeble, probably abolished; ex- 
tension was present, but much diminished. So far as could be deter- 
mined, sensations of touch, pain, and temperature were preserved. 
December 11 (first day after operation). The loss of power in the left 
arm and leg were about the same as noted the day before. Dynamom- 
eter: Right hand, 50; left hand, 26. Sensation was carefully tested 
for and found to be normal. 
12th (second day after operation). The paralysis of the shoulder per- 
sisted, that of the upper arm was increased, and the loss below the elbow 
and in the hand and fingers was more marked. The left leg was 
growing much weaker; the loss of power was most decided below the 
knee. 
13th (third day after operation). The foot movements were almost 
entirely abolished, but some power of flexion and extension of the thigh 
remained. The left upper extremity was completely paralyzed. No 
loss of sensation could be made out in the shoulder or anywhere in the 
upper or lower extremities. 
From December 13th to 20th (third to tenth day after operation) 
the paralyzed left extremities remained the same—paralysis was total in 
the arm and almost so in the leg, the only power retained in the latter 
being that of pushing the leg downward after it had been thrust upward 
and held by the examiner. On December 20th (the tenth day after 
operation) the patient had slight power of extension and flexion of the 
thigh, and marked increase of power of extending or thrusting the limb 
downward against resistance. Gradually power returned in the lower 
extremity, as nearly as could be made out in the following order : Thigh 
extension, thigh flexion, abduction, adduction. Until January 3d (the 
twenty-fourth day after operation) no foot movements below the knee 
returned. At this date signs of flexion and extension at the ankle ap- 
peared. January 2d, she could flex the leg over the thigh, and cross 
the left leg over the right, and could perform, but in a feeble manner, 
all movements of the foot and leg. 
No change was observed in the paralysis of the arm until December 
29th (nineteenth day after operation) when, if the forearm was slightly 
flexed, she could extend it; at this time, as above noticed, she had re- 
gained considerable power in the lower extremity. January 1, 1891 
(twenty-second day after operation) she began to flex the distal and 
second phalanges, but had no power of phalangeal extension, and no 
wrist movements. On January 3d (twenty-fourth day after operation) 
she could flex, extend and separate the fingers and hand, but had no 
elbow or shoulder movements. On January 6th (the twenty-seventh day 10 
MILLS, KEEN, JACKSONIAN EPILEPSY. 
after operation) she gained decided power in flexing and extending the 
elbow, and on January 7th (the twenty-eighth day after operation) she 
could elevate the arm nearly in a horizontal line. On January 12th (the 
thirty-third day after operation) she had regained all movements of both 
upper and lower extremities, and had been able to walk for several days. 
The limbs remained weak, and this weakness continued most decided for 
shoulder movements. All true paralysis, however, had practically disap- 
peared. 
The order iu which paralysis of different muscular groups appeared 
and disappeared is of considerable physiological interest. 
Knee-jerk was found to be increased on the left side, and ankle clonus 
was present on the day after operation. Gradually the exaggerated 
knee-jerk diminished, and on December 23d (thirteen days after opera- 
tion), when the power of flexing and extending the thigh had greatly 
improved, ankle clonus disappeared. 
History of spasms after operation. At 4.30 p.m, on the day of the 
operation, the patient had a slight attack without unconsciousness, in 
which the right arm at the elbow and wrist was flexed, but the arm was 
not carried over the chest as in the old attacks; the head was drawn to 
the right. The left extremities and face and the right leg were not 
involved. 
December 11 (first day after operation). She had light seizures at 5, 
6 and 8.30 p.m. The spasm affected both arms and the left leg. 
12th (second day after operation). Attacks at 4, 7.30, 8.30 and 10.30 
a.m., and 12.50 p.m. Both arms and left leg were involved in the 
spasm ; the head was drawn to the left. At 7.30 p.m. she had an attack, 
the spasm affecting both arms and left leg; the head was drawn to the 
right. 
16th (third day after operation). Attacks at 1.35, 5.40 a.m. Both 
arms and right leg were affected ; the head was drawn to the right. She 
had other attacks in the afternoon and evening. 
14th (fourth day after operation). Attacks at 6.45, 8.30, 9.30 a.m. ; 
none p.m. Both arms and right leg were involved ; the toes were flexed ; 
the head was drawn to the right. 
15th (fifth day after operation). Attacks at 12.15, 1.15, 7.45 a.m., 
affecting the arms and right leg; the head was drawn to the right. 
16th (sixth day after operation). No attacks. 
17th (seventh day after operation). Attacks at 4.30, 6.45, 7.45 a.m., 
spasm invading both arms and left leg; the head was drawn to the right. 
A careful daily record was kept of the spasmodic seizures until Feb- 
ruary 1, 1891—that is, for a period of nearly eight weeks after the 
operation. She averaged four or five attacks daily, occasionally only 
one, two, or three. The majority of these seizures were in the early 
morning hours, between 1 and 2 a.m. They were commonly of moderate 
severity, none of them as severe as the frequent attacks which she had 
had several weeks just preceding the operation. The character of the 
attacks was usually as already described, but they varied somewhat at 
different times. As a rule, both arms took part, the right upper ex- 
tremity becoming spastic in flexion, the left either in extension or 
extended and affected with some clonic spasm ; the left leg was usually 
extended, but was sometimes flexed. The right leg, when included in 
the spasm, was usually semi-flexed at the hip and knee. During the 
week from January 26th to February 1st, the average number of seizures MILLS, KEEN, JACKSONIAN EPILEPSY. 
11 
was somewhat smaller, on the 26th being only three, on the 31st two, 
and on the other days three, four, and five. So far as the distribution of 
the spasm in different parts of the body was concerned, their severity 
was somewhat influenced by the varying degrees of loss and recovery of 
power on the side paralyzed after the operation. About three days after 
the operation, as will be recalled, the paralysis of the upper and lower 
extremity was almost complete, and for several days the left leg took 
little part, or no part, in the spasm, taking, however, an increasing part 
as power was recovered. The same was true of the left arm. During 
most of the time that these notes were taken the spasms preponderated 
on the right side, the morbid ascendancy of the left side, however, re- 
asserting itself as power was more and more recovered. 
This patient has been seen at longer or shorter intervals from the time 
of operation—December 10, 1890—to July 7, 1891. Her history has 
been a monotonous one, and can be condensed into a few sentences. 
Usually she has had about three attacks of spasm in twenty-four hours, 
these, as a rule, occurring during the night, most commonly in the early 
morning hours. Sometimes she has had an attack after daylight, be- 
tween 6 and 8 o’clock in the morning. Occasionally she has had two 
attacks in succession. The spasms have never attained the severity or 
frequency which they had for a short time prior to the operation. She 
had then as many as twelve to fifteen in twenty-four hours, often with 
total unconsciousness, involuntary urination, and subsequent great 
dazing and confusion of mind. At the time of the last examination and 
report, and for some time previous, the attacks usually began with a 
feeling of numbness in the left shoulder and a liftingand jerking movement 
of the entire left arm. The spasm spread, involving the left side and 
sometimes also the right side. Sometimes she was unconscious in the 
attack, but as often not. She now has good use of both the left arm and 
the left leg, all movements being preserved. The left arm, however, 
shows some general weakness, is easily fatigued, and the patient thinks 
that over-use of it brings on the spells. Her general health is good— 
better than for a long time—and she has gained from five to ten pounds 
since the operation. 
The small growth of granulation, with the attached piece of dura 
mater, and also the excised segment of cortical and subcortical tissue, 
were placed in the hands of Dr. Allen J. Smith for microscopical exami- 
nation. Dr. Smith has prepared six slides showing the appearance of 
the membrane, growth, or granulation, and of the excised cortex. He 
reports that connected with the growth or granulation are spots of hem- 
orrhagic pachymeningitis, and several points in its interior which are 
decidedly sarcomatous. He also reports that beyond the engorgement of 
the vessels and the presence of hemorrhage at the surface, and at one 
point at the margin, that the excised cortex was apparently normal. 
At the time of the operation the general impression of those present 
was that the small growth was a large, isolated, pacchyonian granu- 
lation, which had perforated the dura and eroded the inner wall of the 
skull. The microscopical examination throws a doubt upon that view, 
and makes it more likely that after all we had a real neoplasm of very 
small size; but perhaps, without further investigation, the question may 
not be regarded as absolutely decided. If the growth was sarcomatous, 12 
MILLS, KEEN, JACKSONIAN EPILEPSY. 
other sarcomatous foci may be present in the brain; and it was in part 
because of the suspicion that a subcortical mass might be present that 
the cortex was excised. It is not improbable that the other hemisphere 
may contain a growth, as the localizing symptoms Avere at times confusing. 
The patient had clonic spasms of the right arm, although, as has been 
stated in the clinical history, the symptoms began on the left side and 
the attacks were initiated by both sensory and motor disturbances on 
this side. Since the operation right-sided spasms have often been a 
striking feature. 
Supposing that the small tumor was a pacchyonian formation, it would 
be by no means certain that this had not to do with the causation of the 
spasmodic phenomena; and still another view that might be taken is that 
such a formation had resulted from the frequent and long-continued 
localized cortical discharges with their accompanying hypersemia. The 
question of pacchyonian formations in general, and particularly of those 
which we sometimes see either isolated or in small groups, may have some 
mportance in connection with the subject of cortical epilepsy and paresis. 
The nature of these granulations is probably still an unsettled matter. 
Little, at least in late years, has been written about them ; but an inter- 
esting article is that by W. Browning,1 from which I may cull a few 
facts and views applicable to the present case. These formations grow 
from the pia-arachnoid, both over the sulci and over the crests of the 
convolutions. It seems to be universally admitted that these formations 
are limited to certain parts of the pia-arachnoid, showing a decided 
preference for the sides of the longitudinal sinus and the vicinity. Some, 
but not all, of these granulations are connected with the veins and 
sinuses. 
Other structures connected with them are the parasinoidal spaces, 
which occur along the sides of the longitudinal sinus, and are of the 
largest size at the crown of the head. Browning suggests that these 
are important accessories to the veins and sinuses as regulators of the 
cerebral pressure. Sometimes the pacchyonian granulations and para- 
sinoidal venous spaces are combined and connected. When venous 
spaces are present the granulations are not likely to cause depressions in 
the skull. It would seem from these facts that whether a pacchyonian 
granulation would or would not cause greater or less cortical irritation 
might depend upon its peculiar location, and the presence or absence of 
venous spaces into which it could grow. A growth such as was found 
at this trephining may have caused considerable irritation. 
On the other hand, as already intimated, such a formation may have 
been the result of repeated discharges of the adjacent cortical area. As 
1 The American Journal op the Medical Sciences (n. s.), vol. lxxxiv., October, 1882, 
p. 370. MILLS, KEEN, JACKSONIAN EPILEPSY. 
13 
Browning states, and as I can verify from abundant experience at the 
Philadelphia Hospital, many morbid conditions may favor the develop- 
ment of these bodies, one of which of great importance is chronic 
alcoholism. This writer also states that in cases of brain tumor an ex- 
cessive development of these pacchyonian bodies has often been found. 
They have often been found in adults and children suffering from menin- 
gitis, and probably some granulations, particularly those associated with 
meningitis, may be inflammatory in origin, and in reality somewhat 
different from the usual pacchyonian growths. Formerly they were all 
regarded as inflammatory. Browning shows that, while much evidence 
may be had in support of hvpercemia as their cause, some facts do not 
harmonize with this hypothesis. He holds rather to a mechanical 
cause, depending in some way upon the ebb and flow of the blood of the 
veins just above the sinuses. It is not hypersemia of the venous blood as 
such, but the blood acting as any other fluid of its consistence would do. 
Some clinical symptoms have been attributed to pacchyonian granu- 
lations, but only a few can with any positiveness be regarded as due to 
these formations. Browning refers to cases where such granulations were 
present near the Gasserian ganglion and the motor nerves of the eye, caus- 
ing ocular neuralgic and paretic symptoms. Meyer refers various neur- 
algias to them. Headaches have been attributed to them in some instances, 
but with doubtful propriety. Possibly they may cause sinus thrombosis. 
They sometimes produce little flat elevations of bone along the median 
line of the crown of the head. I do not know of any record of cases 
of spasm, local or general, which could be clearly attributed to pac- 
chyonian bodies. Browning refers to a varix of the sinus longitudinalis 
which he believed developed from the parasinoidal spaces, and quotes a 
case of Meschede in which a patient had suffered from epilepsy for thirty 
years, and after death a varix the size of a bean, which had reduced the 
bone to paper thickness, was found. :plje Jotirijal 
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