REPORT OF TWO SUCCESSFUL CASES OF 
TREPHINING FOR TRAUMATIC 
EPILEPSY.* I 
By CARLOS F. MACDONALD, M.D., 
MEDICAL SUPERINTENDENT N. Y. STATE ASYLUM FOR INSANE CRIMINALS. 
The operation of trephining the skull having been per- 
formed at the State Asylum for Insane Criminals under my 
charge, in two cases of traumatic epilepsy during the past 
year, and in each instance with favorable result, as regards 
the epileptic seizures, I venture to occupy your attention 
with a brief recital of the cases, in the hope that they may 
prove clinically interestingj/and also for the purpose of add- 
ing them to the list of recorded cases of trephining opera- 
tions upon the skull for the relief of epilepsy of traumatic 
origin. 
Case I.—J. M. ; male ; age twenty-nine. Convict; ped- 
dler by occupation, and of intemperate habits. Admitted 
to the asylum Nov. 6, 1885, as a case of acute mania. 
Certified cause of insanity, a blow on the head ; which, 
patient claims, was inflicted during a street fight in New 
York City, in the year 1880; he at that time having 
been struck by a policeman’s club and knocked senseless. 
He was picked up and removed to a hospital in an uncon- 
scious condition ; he regained consciousness soon after ad- 
mission to the hospital ; but was ill for about two weeks, as 
* Read before the Third District Branch of the N. Y. State Med. Ass’n at Binghamton, 
N. Y., June 17, 1886. 
Reprinted from the Journal of Nervous and Mental Disease, Vol. xiii., 
No. 8. 1886. 2 
TREPHINING POR TRAUMATIC EPILEPSY. 
an effect of the blow. Subsequently, and up to the time of 
his reception in the asylum, he suffered much from attacks 
of vertigo, was irritable and quarrelsome ; and frequently 
became a participant in fights and brawls. On admission 
he exhibited delusions of persecution and poisoning; was 
excited, noisy, and seemed to be suffering from great pain 
in the head. His pupils were unequal and markedly dilated, 
the right the more, and it was with difficulty that he was 
prevented from doing serious injury to himself by striking 
his head violently against the wall and floor; which he fre- 
quently and determinedly endeavored to do. 
An examination of patient’s head revealed an accentuated 
depression of the skull, irregularly circular in shape, and 
about inches in diameter. It was situated above and to 
the left of the right ear, three inches superior to the ex- 
ternal occipital protuberance, and two inches to the right of 
the median line, approximately covering that part of the 
posterior segment of the superior parietal lobule lying just 
above the deep interparietal fissure. 
Dec. 2, 1885.—After breakfasting the patient fell in a fit, 
while still in the dining-room ; he was convulsed and uncon- 
scious fora few minutes, then, partially regaining conscious- 
ness, he attacked the attendants who were caring for him, and 
violently resisted their efforts to remove him to the ward. 
On the evening of the same day he suffered a similar attack, 
and remained excitable for some time after emerging there- 
from. During the interim he was irritable for a great part 
of the time and disposed to attack, without provocation, 
those about him. At this time he was seen by Dr. Stephen 
Smith, State Commissioner in Lunacy, who concurred in 
advising trephining as a probable means of relief, if not cure. 
I might state that the patient, when free from the epileptic 
paroxysms, was anxious to have the operation performed. 
Dec. 15, 1885.—Patient suffered from three distinct and 
separate attacks on the 12th inst., also a single seizure on 
the 13th and 14th, respectively. Each attack was described 
by the patient as having been preceded by a well-marked 
aura, likened by him to the sensation of having received a 
blow on the head at sifie of depression, with sharp, lan- CARLOS F. MACDONALD. 
3 
dilating pains in superior posterior cervical region. These 
prodromic symptoms were, in each instance, followed by 
vertigo and loss of consciousness; also pain in the region of 
temples on recovering. 
The seizures were not usually of the complete grand mal 
type, but rather that of minor epilepsy or petit mal. 
On December 16th the operation of trephining was per- 
formed ; previous to which, however, the head was shaved, 
and a photograph thereof, showing site of depression, taken. 
Ether having been administered, a crucial incision was 
made over the depression and flaps reflected back. A 
conical trephine was then applied just above the point of 
greatest depression. With little difficulty the disc of bone 
was removed. At the point trephined the skull was found 
to be nearly three eighths of an inch in thickness, quite vas- 
cular, and much roughened on the under surface by rudi- 
mentary osteophytes, to which the dura mater appeared to 
be slightly adherent. Proceeding to remove the remaining 
portion of depressed bone by gnawing with the rongeur, 
that instrument was broken before much had been accom- 
plished. Twenty minutes elapsed before another could be 
procured ; and in the interim a second opening, the site of 
which was contiguous to and overlapped the first to nearly 
a third of its extent, was made with the trephine. Then, 
with the new ro\geur, the bone was gnawed away until all 
of the roughened portion of the inner table was removed, 
leaving an opening in the skull which measured approxi- 
mately one and a quarter inches in length by one in breadth. 
In removing the second button of bone the dura mater 
was slightly wounded by the trephine. The exposed por- 
tion of the dura also presented a congested and thickened 
appearance. After having carefully trimmed the sharp edges 
of bone, the scalp wound was closed by horse-hair sutures, 
dressed with iodoform and lint, and covered with absorbent 
cotton and a skull-cap bandage applied. 
Owing to breaking of the the operation was 
somewhat tedious, the patient’s pulse flagging toward the 
latter part thereof, which necessitated the hypodermatic 
injection of whiskey. 4 
TREPHINING FOR TRAUMATIC EPILEPSY. 
Dec. 17, 1885.—Patient rallied well and quickly from the 
operation, but suffered from nausea all night and got little 
sleep in consequence. This morning feels cheerful. Temp., 
99.40 ; pulse, 100 ; respiration, 20. At 7 and 10 A.M., re- 
spectively, morphiae sulph., gr. J, was administered ; also 
calomel, gr. ; the latter to relieve nausea. Evening temp., 
990; pulse, 84; resp., 20. Patient is rational and cheer- 
ful, and says he feels much better. 
Dec. 18, 1885.—Patient was given chloral, gr. xx., last 
night, and slept well for about four hours. This morning 
his temp, was 990 ; pulse, 88 ; resp., 20. Evening temp., 
99.40; pulse, 100; resp., 24. Complained of some pain at 
seat of wound. Was given chloral, gr. xxx., at bedtime. 
Dec. 19, 1885.—Temp., 990 ; pulse, 88 ; resp., 20. The 
dressings were removed to-day; incisions found to have 
healed by first intention. No unfavorable symptoms have 
yet developed. He has been taking quiniae sulph., gr. ii., in 
half an ounce of whiskey t. i. d. Appetite improving. 
Dec. 23, 1885.—The stitches were removed to-day, the 
wound having thoroughly healed. 
Dec. 28, 1885.—Patient sat up for a short time to-day. 
No pain in the head. Is doing well in every respect. 
June 16, 1886.—Patient’s improvement has been steady 
and uninterrupted. He has been under close observation 
day and night since the operation, and up to date has had 
no return of the epileptic attacks. The marked irritability 
and want of control from which he was suffering when ad- 
mitted to the asylum have subsided, and his bodily and 
mental conditions are much improved.1 
CASE 2.—J. C., male ; aged twenty-four, convict. Driver 
by occupation; native of New York. Admitted July 11, 
1884, as a case of epilepsy. Of intemperate habits. Phys- 
ical condition fair. Has a depression tm skull, the result of 
falling down a flight of stairs when about six years old. 
July n, 1884.—Patient is quiet. Pupils dilated. Claims 
he has no delusions, but that he has been insane several 
times. Confined in Ward’s Island Asylum three times. 
1 J. M. was discharged recovered and returned to the prison, June 24, 1886, 
where he has remained free from epilepsy to the present time, Aug. 1, 1886. 
—C. F. M. CARLOS F. MACDONALD. 
5 
First and second times remained two years : third time over 
three years. Was discharged from that institution in the 
spring of 1884. Depression in the skull, referred to above, 
is behind and above the right ear, two and one half inches 
superior to external occipital protuberance, and one inch to 
the right of the interparietal commissure, covering the 
posterior segment of the superior parietal lobule lying just 
above the deep interparietal fissure. Patient exhibited no 
motor disturbance or impairment of the general or special 
sensory functions. 
Patient’s history previous to admission to asylum is that 
of a chronic epileptic, and is as follows: Fits began at six- 
teen years of age, and have continually recurred up to the 
date of operation. Longest interval of quiescence was while 
under treatment at the asylum on Ward’s Island, when a 
period of fifteen months passed without recurrence of fits. 
Subsequently they reappeared at frequent intervals, the last 
occurring just previous to date of this entry. The seizures 
usually occur at night, marked by convulsions and 
complete loss of consciousness, and followed by a state of 
active mental excitement, during which patient, as a rule, 
becomes noisily maniacal and pugilistic. 
July 14, 1885.—Patient has been quiet and well-behaved 
since last entry; had a fit last night while in bed, but it was 
not followed by the usual mental disturbance. 
From this time until Nov. 20, 1885, he suffered from fre- 
quent nocturnal seizures, which left him each time in a dis- 
turbed mental condition, though not violent. He gradually 
became very whimsical, irritable, unreasoning, and discon- 
tented. This condition persevered until February 18, 1885, 
when he began to complain of pain in the right occipital 
region, most intense over the above-described depres- 
sion. From this up to the day of the operation the 
frequency of attacks increased, always nocturnal, but evi- 
denced by a bitten tongue, and by his having been fre- 
quently found by the night watchman out of bed on the 
floor in a dazed, semi-conscious condition, and incapable of 
telling why he was out of bed. On the 25th of August, 
1885, the operation of trephining was performed. It was 6 
TREPHINING FOR TRAUMATIC EP/LEPSY. 
similar in character to that in the preceding case, except 
that in this there was but one button of bone removed. 
The inner surface of the bone was smooth and non-adhe- 
rent and the dura mater was not wounded. Nothing oc- 
curred during the operation worthy of special comment. 
At 5 P.M., patient, who had rallied well, was given TTj,viii. 
of Magendie’s solution of morphia, hypodermatically. At 
9 P.M., morphia sulphate, gr. was administered per 
A little milk and lime-water was given during the even- 
ing- 
August 26, 188®.—Temperature, 98.5°; pulse, 65 ; respira- 
tion, 16. Appears in good condition. 
Aug. 27, 1885.—Complained of headache during the 
night. Temp., 97.50; pulse, 56; respiration, 16. 
Aug. 29th.—Temperature has not been above 98.5°, in 
axilla, since the operation. Dressings removed. Primary 
union of wound has taken place; not a drop of pus is to be 
found. Wound thoroughly cleansed and iodoform dress- 
ings reapplied. A little puffiness of scalp in vicinity of 
wound was observable, but there were no evidences of sup- 
puration. 
Aug. 31, i88fc.—All stitches removed, and head dressed 
with carbolatea cosmoline and lint. Puffiness, remarked at 
last dressing, has entirely disappeared. Sat up in bed for 
a little while. 
Sept. 15, 1885.—Has been about the ward the past week. 
Is out in the yard to-day. Has complained occasionally of 
slight headache. 
Nov. 18, 1885,—Since the operation, has exhibited very 
little of his former irritability. Complains of headache 
occasionally, but not nearly so frequently. 
Feb. 3, 1886.—Much less irritable, less frequent head- 
aches, no recurrence of fits. 
June 16, 1886.—Up to date patient has remained free 
from epileptic seizures, nocturnal or diurnal, while at the 
same time there has been a considerable degree of improve- 
ment in his mental tone. He now controls himself fairly 
well, and appears to be free from delusions, but exhibits a cer- 
tain amount of weakness of mind, the result of long-con- CARLOS F. MACDONALD. 
7 
tinued epilepsy, and from which a complete recovery is not 
to be expected, even though there should be no return of 
fits.1 
Applying the rules of cranio-cerebral topography to these 
cases, it will be seen that the lesion, in each instance, was 
located over a region of the* brain to which no definite func- 
tion has as yet been namely: the parietal lobules. 
Hence the absence of motor or sensory disturbance such as 
might have been expected from a similar lesion located in 
those areas of the brain which are now generally believed 
to govern motion and general sensation—that is, in the cen- 
tral region surrounding the Rolandic fissure. 
While the existence of organic lesion of the cerebral cor- 
tex in either of the foregoing cases is extremely doubtful, 
it is, nevertheless, a well-established fact that those portions 
of the brain lying outside of the so-called motor zone may 
suffer extensive destructive lesion without giving rise to 
paralysis or other special symptoms of organic cerebral dis- 
ease, though lesions of these unexcitable or non-motor 
regions, limited to or involving the dura mater, not infre- 
quently give rise to localized headache, vertigo, convulsions, 
etc. Irritation of the nerves of the dura mater interferes 
with the blood supply by causing spasm of the dural ves- 
sels, and this in turn excites reflex convulsions of a general 
character, whereas convulsive manifestations arising from 
irritative lesions of the cerebral cortex are, generally speaking, 
definitely localized. Epileptic attacks may also result from 
a lesion of any part of the skull, whether within or without 
the motor centres. In fact, epilepsy has been known to 
arise from the reflex irritation following a fracture of the 
outer table with no direct pressure on the subjacent parts. 
Mr. James F. West reported to the Royal Medical and 
Chirurgical Society, in 1879, a case this kind, of seven 
years’ standing, which he cured by trephining. 
* Surgical history tells us that formerly it was customary 
to trephine in cases of epilepsy that resisted medical treat- 
ment, but the practice gradually fell into disuse, probably 
‘August i, 1886.—Patient is still under observation. He has had no fit 
to date.—C. F. M. 8 
TREPHINING FOR TRAUMATIC EPILEPSY. 
on account of the numerous failures resulting from want of 
discrimination in the selection of cases upon which to 
operated as well as the gravity of such operations before the 
dawn of antiseptic surgery. In 1852 Prof. Stephen Smith, 
of New York, in an article on the Surgical Treatment of 
Epilepsy, collected and analyzed 35 cases of trephining, giving 
the results of the operation and ably advocating its adoption 
in cases dependent on depressed fracture of the skull. Prof. 
John B. Roberts, in his recent valuable essay,1 refers to 
92 American operations collated by Stephen Smith, Billings, 
and Echeverria, of which 63 were cured, 13 improved, 2 un- 
improved, and 14 died. This author also cites 130 cases 
collected by Walsham, of which 75 were cured by the oper- 
ation, 18 improved, 7 unimproved or worse, and 30 died ; 
also “ 30 cases of epilepsy from old injuries of the head have 
been operated upon by Briggs,2 of these 25 were cured, 3 
ameliorated, 1 not changed, and 1 died.” 
That the cessation of the fits in the two cases here reported 
was directly due to the operation, will not, I believe, be 
questioned. In this connection the question naturally 
arises, would the mental impairment resulting from the 
long-continued epilepsy have been prevented by an earlier 
resort to the trephine? The writer is of the opinion that it 
would. 
In view of the high ratio of recoveries in the com- 
paratively large number of cases here cited from reliable 
sources, together with numerous other successful cases 
which, for. want of time, I have not attempted to bring to 
your notice, it is not surprising that both surgeons and 
neurologists of the present day, almost without exception, 
should not only sanction, but advocate, an operation which 
promises so much in the way of cure, and which, with 
proper antiseptic precautions, is attended with so little 
danger to the patient. 
1 “ The Field and Limitation of the Operative Surgery of the Human 
Brain,” 1885. 
’ Transactions of the Am. Surgical Association, 1884.