these seventy-eight, two were excluded because of organic diseases of the eyes which rendered them useless for the purposes of the tests in view. Five more were excluded because of the impossibility, due to psychic or ocular amblyopia, of diagnosticating the ametropia. This left seventy-one cases. Of these, three were excluded because the ametropia was of so low a degree that it was thought negligible. These patients needed no glasses, either for the relief of ocular conditions or of reflex results. Only about 4 per cent., therefore,-three out of seventy-one cases,— seemed to us to have eyes so near normality of optic conditions that they required no further attention.

"Our tests, therefore, concern sixty-eight cases,thirty-five men and thirty-three women. These were chosen for us by the superintendent regardless of all conditions of epilepsy, age, etc., except that we requested that only patients be given us who were sane and who could read.

"The errors of refraction were estimated only after thorough paralysis of the accommodation by means of homatropin and cocain. Dr. Bennett diagnosticated the muscle-imbalance, made the ophthalmoscopic examinations, and estimated the refractive errors objectively by means of the retinoscopic method. Dr. Gould made the subjective refraction and accommodation tests, and dictated the prescriptions. The subjective tests were in all cases those finally relied upon when the patients' answers could be trusted, and the results seemed the more accurate.

"The following table of the sixty-eight cases shows:

9

vision or less (with correction).

Regular isometric, compound astigmatism.

Simple regular astigmatism.

Simple hyperopia.

Simple myopia.

Absolutely isometric, i. e., about 77 per cent.
had anisometropia.

"The muscle-imbalances for any high or complicating significance were unexpectedly absent. Indeed, in but one case did we think them worth consideration, so far as final correction was concerned.

"The astonishing fact, and one that we think deserves most serious attention, is the enormous proportion among these patients of cases of injurious astigmatic and anisometropic defects; in sixty-seven out of sixty-eight cases there was astigmatism; and it is most noteworthy that about half of the entire number of patients had unsymmetric astigmatism, a defect which almost inevitably produces the most injurious results upon cerebral and assimilative function. This terrible incidence of unsymmetric astigmatism in epileptics is, we judge, twenty or more times as great as in ordinary patients. We do not say that these high and most injurious ametropic defects caused the epilepsies of these patients. That can only be determined in the future by the careful records of seizures to be kept and compared with those of the past. If none of the patients is cured by the relief of eye-strain it would still not disprove the theory that in a certain number the eye-strain might have been the initial cause."

The sixty-eight patients were carefully fitted with glasses by an expert optician, were placed under the care of a physician who saw them daily to insure proper wearing of their glasses, and a record was kept of all attacks, day and night, for a year after. The following table gives the results in detail in all presenting an unbroken record in the period of treat

ment for three months before and three and six months after wearing glasses.

The results at the end of the year were not far different from those at the end of six months.

TABLE SHOWING RESULTS OF RELIEF OF EYE-STRAIN IN

EPILEPSY.

MALES.

Months

Wearing Glasses.

Number of Attacks

during

21

112

II

19

Following

the

Wearing of Glasses.

༦༥༠༠སཱུ

3960

*These cases passed from under observation at the end of the first three months' period.

16

344

ΟΙ

24

204

41

3

119

25

о

The results of this experiment so carefully made were not encouraging. The nearest approach to a cure was in case No. III (male). This patient had no attacks in June, eight in July, and four in August, the three months preceding the use of glasses. He began to wear them September 1, 1902, and had eight attacks in the next twelve months, four in September and four in October, 1902. His attacks were grand mal, always severe, and universally began with a bilateral arm aura, both hands finally being jerked above the head some time before the fit.*

Some patients (four or five) declared that the use of glasses had benefited them in some way, mostly in the relief of headache.

The totals show that the thirty-one males had 766 seizures during the three months prior to the wearing of glasses, 765 during the first three months after, and 1332 during the first six months after; that the thirtythree females had during three similar periods, 670, 592, and 1426 seizures.

*After going 14 months without an attack, they recurred in January, 1904, as severe as ever.

CHAPTER XV.

THE SURGICAL TREATMENT OF EPILEPSY.

Types of Epilepsy Suitable for Surgical Intervention. Jacksonian and Grand Mal, Idiopathic, Organic, Traumatic. Clinico-pathologic Guides to Operation. Technique of Trephining. Technique of Abdominal Section with Indications for the Performance of Each. Results.

THE presence of epilepsy being established, there are two essential preliminaries to be observed before undertaking any operation upon the brain for its possible relief:

1. The determination of its type and cause.

2. The determination of the point on the cranium at which the operation is to be performed.

Both embrace questions of the utmost importance, the determination of which rests with the physician before the surgeon can be called upon to operate.

In some forms of epilepsy surgical intervention is permissible, often valuable, less often curative; but in others it is wholly unjustifiable.

At the outset we exclude from surgical consideration, so far as operations on the brain are concerned, petit mal, psychic, hystero-epilepsy, serial attacks, and status. Rarely we may find accidental and isolated occasions for operating on some of these, but even so, the principles and methods applicable in other types apply fully as well as in these.

The surgical treatment of pseudo-epileptic convulsions that follow peripheral irritations will be mentioned later.

Excluding the inoperable ones enumerated above, we have but two varieties left for possible surgical treatment, and these are grand mal and Jacksonian