Trephining in Epilepsy. 
J. T. BOUTELLE M. D., 
of Hampton, Va. 
Read before Twenty-fifth Annual Session of Medical Society of 
Virginia, held in Richmond, October 23-25, 1894. 
REPRINTED FROM TRANSACTIONS. Trephining in Epilepsy 
J. T. BOUTELLE, M. D., of Hampton, Ya. 
There is scarcely any condition to be met with in surgical 
practice which, at first sight, seems more imperatively to demand 
operation, or in which the operation seems more certain to ful- 
fill the terms of the maxim, “Causa sublata, tollitur effectus,” 
than traumatic epilepsy. But as we examine the recorded re- 
sults of such operations, we find little to boast of as regards cer- 
tainty of cure, and the prospect of brilliant success grows de- 
cidedly dim. Cures are, of course, effected, but by no means to 
the extent we should naturally expect. 
We have two causes to contend with—first, an abnormal con- 
dition of the skull either in shape or structure produced by 
injury, which, by pressure or irritation for a considerable length 
of time, brings about the second—viz: the tissue change or 
molecular disturbance of the grey matter of the brain, and this 
is the immediate cause of the epilepsy. This condition of the 
grey matter may spread over an area of uncertain size or be 
confined to a small spot. When the molecular change in the 
brain-tissue has reached a certain degree, epilepsy begins, and 
goes on gradually increasing in violence. Then the question 
naturally arises—Do we expect to cure the disease by removing 
the primary cause ? 
Up to within a few years, the operation consisted of remov- 
ing the depressed portion of the bone or of simply taking out 
a button over the site of injury. This was formerly a serious af- 
fair, but antiseptic surgery has rendered it as safe as almost any 
other operation. 4 
Modern methods of surgery and the immense advance of neu- 
rological science in localizing the motor centres of the brain 
have emboldened surgeons to go much further than formerly. 
The new, or modern, operation consists of trephining over a 
very large area, opening the dura, examining the surface of the 
brain, removing cysts or growths, and in excising a portion of 
brain substance from the centre indicated by the special symp- 
toms in each case. One of the chief features of this operation is 
that it is performed for non-traumatic cases. 
By the old operation, a fair amount of success has been ob- 
tained, either cure or marked amelioration in a respectable 
number of cases—certainly enough to justify the operation. If 
we believed many of the statistics collected to be beyond criti- 
cism, we should speak much more enthusiastically. I shall not 
attempt, in this paper, to give complete statistics, but will call 
attention to a few. 
Walsham’s collection gives, out of 82 cases, 48 cured and 13 
relieved. 
Dr. W. Briggs reports, out of 30 cases, 25 cured and 3 relieved. 
Such results as these would justify almost any serious operation. 
In 1872, I reported a collection of cases performed at the Mas- 
sachusetts General Hospital up to that time—12 cases, 4 cured, 
1 relieved, 7 deaths. Boston Med. and Surg. Jour., Feb. 22, 1872. 
In the American Journal of Medical Sciences, November, 1892, 
Drs. Gerster and Sachs report 10 cases. No cures—1 great im- 
provement, and 1 slight improvement. These last are un- 
usually frank statistics. 
In most of the individual cases I have looked up, which are 
classed as successful, the record generally reads, “No fits two to 
eight months after operation when last heard from,” and we 
never hear any more about that case. Very few records show 
observation of the case after six or eight months. 
If a country surgeon does this operation, and it is not suc- 
cessful, he will never be allowed to forget it. I believe that a 
s ccessful record, to be of any value to the surgeon, must be 
that of a case which has been under observation from two to 
three years. 
The following two cases from my own practice will serve to 
illustrate a few points of interest: 5 
Case I.—February, 1893. Edw. Johnson, white, ?et. 18, when 
five years old, received a blow on the head from an axe which 
fell from a shed and cut through the skull. No doctor was called, 
and he had only home treatment. The wound healed, and he 
never had any symptoms until he was sixteen years old. Then, 
while sparring with another boy, he received a heavy blow upon 
the head, and shortly alter began to have light epileptic attacks, 
which gradually increased in frequency and violence until now 
they occur once to three times a week and are quite severe. 
His parents say that they think his mind is becoming impaired. 
I found a linear depression, running longitudinally over left 
parietal bone about middle of anterior third, abo.ut two inches 
long. My diagnosis was an original fracture of both tables with- 
out depression of inner table—that the blow eleven years later 
loosened some fragment and caused it to change its position and 
produce pressure on the brain. He was taken to the Dixie 
Hospital for treatment. The day before operation his head was 
shaved, scrubbed with soap and water, then with alcohol and 
turpentine, and a compress wet with a solution of mercuric 
bichloride 1-3000 kept on the scalp. 
Operation February 14, 1893. Scalp-flap raised by horse-shoe 
incision. Button removed at each end of the depression, and 
the intervening piece sawed out. For this purpose, I used a 
small circular saw attached to a dental engine, and with this 
one side was sawed through, but in commencing the section 
of the other side the engine got out of order, and the section was 
made with a Hey’s saw. Before completing the second section, 
I passed a flat probe under the skull, and felt a piece of bone 
projecting downward, close to the line of section. This was 
broken off with a small curved dental instrument and drawn 
out. The section was then completed. The dura had not been 
punctured by the fragment, aud was apparently healthy. The 
edges of the opening were then smoothed off, and the opening 
thoroughly irrigated with bichlorid. sol. 1-3000. The flap was 
then adjusted and united by aseptic silk sutures. No drainage 
was used. The wound healed by first intention, and the patient 
never had a temperature above 99.5°. No pus was seen. No 
medical treatment was used until a week after operation, when 
an epileptic attack occurred. He was then put on bromide 
treatment. 
He made a good recovery and went home. I saw him now 
and then for several months, and continued the bromide treat- 
ment. He had no fits for about six months. Since then I 
hear that he went away on a vessel, and while on a cruise the 
fits recurred, and now are as bad as ever. When I saw him 
last the wound was perfectly healed, but a deep depression was 
caused by the sagging of the scalp into the opening. 6 
Case II.—April, 1893. Frank W., white, set. 40. Received 
a blow on the head when six years old, causing depression of 
bone. Ten years after, began to have epileptic attacks, petit 
mal, and these gradually increased in severity and frequency, 
sometimes being very mild, but often severe convulsive attacks. 
He tells me that before the attacks of petit mal he had pecu- 
liar sensations and mental disturbance, for which, at one time, 
a physician was consulted. I found a well-marked, rounded 
depression in right parietal bone about the middle of posterior 
third. He went to the Dixie Hospital, and his head was pre- 
pared as in the case just reported. A button of bone, large 
enough to include the depression, was removed. The dura 
looked healthy, but was slightly adherent around the opening. 
It was easily separated by light pressure with a small flat scapula. 
No projecting bone was found. The button showed some thick- 
ening, but no scar of fracture of internal table. The wound was 
closed as in the first case. No drainage. Union took place by 
first intention. No pus. No temperature above normal at any 
time. 
About a week after the operation, he was much excited by a 
death at the hospital and the loud lamentations of the relatives, 
and had an attack of acute mania, being restrained with difficulty. 
Was then taken home, where he slept steadily for twenty-four 
hours or more, and then recovered his senses. For about two 
months, there was apparently great improvement, and either 
none or very slight attacks of petit mal, but after that time the 
attacks recurred and now are as bad as ever. 
These cases illustrate the old operation under antiseptic 
methods, and are sufficiently typical to emphasize some points. 
In the first place, the healing by first intention, no pus, and no 
fever. In the twelve cases I reported occurring before 1871 were 
seven deaths; the causes of death being suppuration, menin- 
gitis, or sloughing of membranes. It would be rare now to 
find such a proportion of deaths, or from such causes. 
It will be noticed that in these cases benefit was derived from 
the operation at first—in one case no fits for about six months, 
and in the other great amelioration for two or three months, but 
then the disease recurs and gradually resumes its old course. 
This, I fear, would be the history of many a case reported cured, 
if it could be followed up, and I think it is a result for which 
there are many good reasons. It does not require an injury 
severe enough to cause pressure upon the brain by spiculse of 
bone to produce traumatic epilepsy. Case II shows only a 7 
slight thickening of the bone and very slight adhesion of the 
dura. A case was recently reported in the Boston Medical and 
Surgical Journal where a button was removed, no adhesion of 
dura found, and only a slight hyperplasia of the bone. A scar 
of scalp wound occasionally produces the disease, and cases are 
reported where removal of the cicatrix had brought about a 
cure. Any injury which brings about a change in the skull tis- 
sue may cause molecular change in the brain beneath. Slight 
adhesion of the dura to the skull is a sufficient cause. Also a 
tumor in the white matter, near the cortex, will produce epilep- 
tic symptoms. 
Now, when we remove a piece of the skull, we leave behind 
a condition likely of itself to produce adhesion of the dura to 
the margins of the opening, or the scalp sinks into the opening 
and either adheres to the dura or irritates it, and after a cer- 
tain lapse of time we again have a condition which reproduces 
the disease. Then the details of the operation should be such 
as to prevent these sequelae. In the old operation, I see no way 
of doing this except by carefully bevelling and smoothing the 
lower edge and closing the upper end of the opening with 
some hard substance. 
In these cases, we notice that one had a fit one week after the 
operation, and then was put upon bromide treatment, after which 
he was well for a long time. The other had an attack of mania, 
and then was put on medical treatment, and amelioration re- 
sulted. It is certain that operation alone will not cure. Medi- 
cal treatment should be instituted in every case as soon as pos- 
sible after the operation, and continued just as in an idiopathic 
case. 
The modern operation consists, as I have stated, of remov- 
ing not only the depression or a button at the site of the injury, 
but of trephining over an area large enough to allow of a com- 
plete examination of the brain surface. The dura is opened, 
cysts or growths removed, and the motor area to be attacked de- 
termined by faradization. Then a portion of grey matter, and 
sometimes some of the white matter, is excised. 
Nothing can be more thoroughly scientific than this opera- 
tion, and it seems to fulfill every surgical requirement in remov- 8 
ing both the primary and secondary causes. From such a radi- 
cal measure, we should naturally look for the most brilliant 
results. It ought to produce certain and lasting cures, at least in 
the majority of cases. 
But it is a very severe operation, and attended with consid- 
erable risk. It generally demands two agents—one an expert 
in nervous disease to locate the exact part to be removed, and 
the other a more than ordinarily expert surgeon. If the opera- 
tion is successful, it is a brilliant affair, and one to reflect credit 
on all concerned in its accomplishment. But if unsuccessful? 
the patient has undergone a serious risk to life, and still has his 
epilepsy, plus a very large hole in his skull, and a more or less 
permanent paralysis of some part. Motor paralysis of the part 
governed by the centre excised, of course, is a result. It is 
stated by some of the most prominent operators in cerebral sur- 
gery that this paralysis is only temporary, and that the part 
will eventually recover its functions. The patient is also left 
with the same conditions I have mentioned, when speaking of 
the old operation, as possible factors in the recurrence of the 
disease at a later period. 
Then, in order to justify such radical proceedings, we must 
have unusually good results. 
Statistics of this operation are not, as yet, abundant, and I do 
not pretend to give anything like a complete collection; but 
I have examined the cases recorded in the American Journal of 
Medical Sciences for the past six years, and have tabulated an 
epitome of the cases I have found reported, fourteen in num- 
ber. Two of these were caused by tumor of the brain, and 
eight were non-traumatic cases. 
The study of cerebral surgery, as exemplified by many skill- 
ful operations in removal of tumors, is of great interest in con- 
nection with the subject under discussion. I have only col- 
lected the cases in which epilepsy was a prominent symptom.. 9 
No. 
Case. 
Reporters. 
Journal. 
Results. 
1 
Right-sided Jacksonian 
Drs. Weir 
Amer.Jour. 
Recovery. Temporary 
Epilepsy with facio- 
and 
of Medical 
complete paralysis of 
brachial paralysis. Tu- 
Seguin. 
Sciences, 
right limb, and apha- 
sia. Eventually re- 
mor of left hemisphere 
July, 1888. 
involving centres for 
gained speech, and the 
face and right arm. 
paralysis improved. 
Trephined and tumor 
Seven months after op- 
removed. Bone disks 
eration was having oc- 
replaced, and united 
casional slight spasms. 
firmly. 
Much relieved. 
2 
Epilepsy of uncertain 
Dr. W. W. 
Ibid., 
Recovered from opera- 
origin. Attacks com- 
Keen. 
November, 
tion in eight days. 
mence in right hand. 
1888. 
Left arm paralyzed, 
Trephined over fissure 
but showing signs of 
of Rolando,dura raised 
improvement. Two 
and centre for left 
months after, the epi- 
hand and -wrist ex- 
leptic attacks were di- 
cised. 
minished in frequency 
and wrere only petit 
mal. Much relieved. 
3 
Focal epilepsy of severe 
Drs. Lloyd 
Id., 
Recovered from opera- 
character. Attacks 
and 
Novemb’r, 
tion with motor paral- 
commence in left arm. 
Deaver. 
1888. 
ysis of arm. Record 
Trephined over fissure 
three months after 
of Rolando, right side. 
Three pieces of brain 
shows no convulsive 
attacks, and motion re- 
turning in arm to some 
excised, each f of an 
in. deep and £ in. wide 
at centres for left arm, 
extent. Much relieved 
(or cured). 
hand and face. 
Here four cases of cere- 
Drs. Jacob 
Id, 
bral surgery are re- 
Frank and 
July, 
ported, of which three 
Archibald 
1890. 
are of interest as re- 
gard epilepsy. 
Church. 
4 
Dementia of alleged 
Great improvement at 
traumatic origin. Tre- 
phined, dura raised, 
first, but in 9 months 
epilepsy developed. 
and brain surface ex- 
plored. Buttons re- 
placed and united. 
2nd operation. Adhe- 
* 
sions of dura were 
found, very firm with 
processes running into 
trephine pin openings. 
After 2nd operation, pa- 
Small pieces of bone 
Drs. Frank 
Ibid, 
were partly absorbed 
and 
July, 
tient recovered, and in 
and acted as foreign 
Church. 
1890. 
one month was report- 
bodies; the dura show- 
ed as having no fits, 
ed marks of the but- 
and improved in all 
tons and the intersti- 
respects. 
ces between the but- 
tons showed fibrous 
scar tissue. The cica- 
tricial tissue was dis- 
Much relieved. 
sected off, and the bone 
was not replaced. 10 
No. 
Case. 
Reporters. 
Journal. 
Results. 
5 
Jacksonian epilepsy. 
Trephined and tumor 
of brain removed. 
Five buttons replaced. 
2nd operation. The but- 
tons were found tilted 
and making pressure 
on the brain. Abscess 
of brain found, evacu- 
ated, irrigated and 
drained Buttons were 
not replaced. One was 
left which had united 
properly. 
- 
Ibid., 
July, 
1890. 
Improved for a time, and 
then epilepsy recur- 
red. 
After 2nd operation, re- 
covered. One year af- 
ter, record shows con- 
dition much better 
than before operation, 
but convulsions occur 
about once in ten days. 
Much relieved. 
6 
Idiocy and continuous 
choroid movements. 
Trephined over motor 
zones. Three buttons 
removed and replaced. 
U 
Died on the third day. 
Autopsy showed that 
the buttons were firm- 
ly a d h e r e n t to the 
dura. 
7 
Traumatic epilepsy. Tre- 
Dr. W. W. 
Am. Jour. 
Recovery. No attacks at 
phined, and a portion 
of cortex removed. 
The opening was clos- 
ed by a piece of decal- 
cified bone, stitched to 
the scalp so as to fit the 
Keen. 
of Medical 
Sciences, 
Septemb’r, 
1891. 
time of record, eight 
months after operation. 
The opening is closed 
with firm tissue. 
Cured. 
8 
Jacksonian epilepsy. 
Drs. Mills 
Am. Jour. 
Left limb paralyzed, but 
Trephined over motor 
zone. Small growths 
excised from the dura 
and a portion of cor- 
tex removed. Bone 
not replaced. In this 
case, the fits occurred 
twelve to fifteen times 
in twenty-four hours. 
and Keen. 
of Medical 
Sciences, 
December, 
1891. 
eventually recovered. 
Convulsions continued 
from time to time, but 
less severe and less fre- 
quent. Seven months 
after, record shows an 
average of three fits in 
24 hours. Much re- 
lieved. 
9 
Cortical epilepsy. Fits 
Dr. Alex. 
Ibid., 
Recovered. Seven months 
severe at times, and at 
others mild. Trephin- 
ed over centre for right 
arm. Dura opened. 
No cortical substance 
excised. Brain punc- 
tured by trocar on ac- 
count of bulging. No 
tumor or fluid found, 
Brain surface washed. 
B. Shaw. 
January, 
1893. 
after operation, record 
shows entire absence of 
fits. Complete paraly- 
sis of right arm. 
Cured. 
10 
Traumatic epilepsy. 
Drs. White 
Ibid., 
Recovered, and was well 
Trephined over large 
Novemb’r, 
for six months. Then 
area. Mass of thick- 
ened dura removed. 
and Wood. 
1892. 
the disease returned, 
and intellect failed. 
Of the 10 cases reported 
by Drs. Gerster and 
Sachs, 4 may be class- 
ed with the modern 
operation. 
Drs. Gers- 
ter and 
Sachs. 
Ibid., 
Novemb’r, 
1892. 
No improvement. 11 
No. 
Case. 
Reporters. 
Journal. 
Results. 
11 
Right-sided epilepsy af- 
ter injury. Trephined 
over motor area for 
right arm. Dura punc- 
tured. No cvsts. 
Recovered. No attacks 
for about 1J months. 
Diminution of attacks. 
Case not heard from 
later. Relieved. 
12 
Traumatic Jacksonian 
epilepsy, involving 
muscles of right side 
of mouth. Trephined 
over centre for angle 
of mouth. Adhesions 
found under the but- 
tons. Small cysts on 
dura punctured. 
Drs. Gers- 
ter and 
Sachs. 
Am. Jour, 
of Medical 
Sciences, 
Novemb’r, 
1872. 
No improvement. 
> 
13 
Injury of right side of 
occiput. One year 
later, right hand and 
leg convulsed. Aver- 
ages three to four fits 
in two weeks. Tre- 
phined and motor 
centre on left side ex- 
posed. No cortical 
tissue removed. 
2nd operation 31 days 
later, and arm centre 
removed. 
U 
U 
No improvement. 
14 
Non-traumatic Jackso- 
nian epilepsy, begin- 
ning in left hand. Tre- 
phined and centre for 
left hand removed. 
U 
U 
Some immediate improve- 
ment, but no lasting 
benefit. 
These records then give us three cured, six relieved, four not 
improved, one death. 
If we take the bald result of these statistics, we must say that 
the modern operation makes no better showing than the old. 
Three cases out of the fourteen I have set down as cured, as they 
are just as good cures as are generally reported—i. e., one case 
having no fits up to eight months after operation; one none 
for three months; and one none for seven months, but with com- 
plete paralysis of right arm. We find marked amelioration in 
five cases and slight in one. We cannot say that the excellence 
of results is commensurate with the brilliancy of the perform- 
ance, or that such statistics justify so severe and difficult an 
operation. But in every operation of this kind each case must 
be taken by itself, and on examination we find that these four- 
teen cases were exceptionally bad and difficult to handle. The 12 
non-traumatic cases reflect much credit on the diagnosticians 
and operators. Future study and progress may enable the pro- 
fession to give better results. 
Among the details of the operation, the most important to 
my mind, is the closing of the external opening. For this pur- 
pose many means have been tried with varying success, replacing 
the buttons and filling in the interstices with bone dust, using 
plates of metal, gold, silver, etc., celluloid plates, highly spoken 
of by some operators, and decalcified bone. Making a sort of 
trap-door by sawing three sides and partially sawing the other, 
raising the piece and afterward bringing it down again, is a 
method for which much is claimed. Replacing the buttons 
seems to me attended with as much risk of future trouble as 
leaving the hole open. The buttons may tilt and cause pres- 
sure; they may partially absorb and act as foreign bodies, or 
may necrose and have to be removed by a subsequent opera- 
tion. In the above table we find a case where the operation was 
done for idiocy or some cerebral trouble, the buttons replaced, 
and after a length of time epilepsy came on. The buttons were 
found partially absorbed, some tilted and generally causing cere- 
bral disturbance. In another case in which death occurred 
after three days, the buttons were found adherent to the dura, 
which I think would have eventually caused epilepsy had the 
patient lived. 
The most successful case in every respect among the above is 
one of Dr. W. W. Keen’s, in which he closed the opening by a 
piece of decalcified bone, and this is a method which I think 
ought to be followed up and given further trial. 
As to instrumental methods of removing the bone, surgeons 
differ, some preferring the large trephine and rongeur, others the 
mallet and chisel, and others the circular saw. I only pro- 
pose to speak of one, of which I have had personal experience, 
viz., the circular saw and dental engine. The only fault I 
have to find with it is that it is too good. It cuts bone with 
such ease and rapidity that it requires a light hand and much 
dexterity, and as we approach the inner surface we feel much 
anxiety lest it may cut through into the brain. The guard, 
which can be attached to the saw, cannot be regulated so as to 13 
be right for the varying thickness of the bone to be cut. After 
I had succeeded in making one section with this instrument, 
I was much relieved when the engine broke down and I could 
take a Hey’s saw in my hand and go ahead with confidence. 
In spite of the remark I find in Wyeth’s Surgery that Hey’s 
saw is a useless thing and should be discarded from among sur- 
gical instruments, I must say that I used it with great satisfac- 
tion in this case. 
In connection with this subject the question always arises of 
early trephining in injuries of the skull, and when trephining 
should be done. In view of the fact that the operation itself 
may be a factor of future trouble, does it seem best to trephine 
immediately for every injury which may possibly cause epi- 
lepsy in the future? To my mind, certainly not. To trephine 
when there is no depression, or a simple fracture of one or both 
tables, unless symptoms are present demanding such interfer- 
ence, seems to me uncalled for and just as likely to produce epi- 
lepsy as the criginal injury. But after a certain lapse of time 
from the receipt of injury certain symptoms may develop, per- 
haps petit mal, or even before such indication, some mental 
disturbance or peculiar sensations which cause a consultation 
with the physician. This is the time. The moment any cere- 
bral disturbance shows itself, after injury to the skull, is the 
golden moment for operation. The longer we wait gives the 
disease a better hold and it will increase in violence, and the 
longer it has lasted, the less the hope of cure. 
The modern operation seems to be the only surgical means of 
effecting a cure or amelioration in the non-traumatic cases of 
focal epilepsy. 
In traumatic epilepsy, I should say the old operation was the 
best, and advise operating at the very earliest symptoms of cere- 
bral trouble, bevelling and smoothing the lower edges of the 
opening and closing the outer opening by the best method pos- 
sible, and commencing medical treatment immediately after the 
operation. But if we find clear indications for opening the dura, 
the records of recent cerebral operations show that this pro- 
ceeding is not attended with the grave dangers to life that we 
formerly feared. s