the knife and the trephine; they have not reasoned thoroughly and have not discriminated well between those cases to which operation offered a probable relief and those to which it did not. Many poor, old, imbecile epileptics have had holes sawed in their skulls when it was almost as useless to think of stopping their fits as it would be to think of turning back Niagara with a dam of feathers. Again, statistics and reports of cases operated upon have been so frequently misleading because an insufficient time has been allowed to elapse after the operation to justify the opinion as to which were cured and which were not. As a rule these reports have been entirely too optimistic. This brings up the question. What is a cure of epilepsy? This is a very difficult question to answer, and one which, in statistical tables, must be determined arbitrarily. We should not lose sight of the fact that there is frequently a spontaneous remission of the fits; that a change in treatment, even though it be from some of the drugs of known value to a mere placebo, may be followed by a temporary cessation; a mere change of environment will do the same, and any operation, whether it be on the brain or on the buttock, will usually do as much. The table upon which this article is based is made up of forty-four cases,' that I tabulated at the request of my friend Prof. Landon Carter Gray for his article on Epilepsy in "Nervous Diseases by American Authors," to which I have here added twenty-six cases, all having been taken at random from medical journals, making seventy cases in all. In this table I have regarded as cured all cases in which there has been no return of the fits within three years after the operation; i.e., all cases which have been under observation for three years or more after the operation, and in which there has been no return of the fits during that period. With this as a basis I get the following results: A After a careful tabulation of these cases, and after having invariably given the benefit of the doubt to the reporter, we can only find undoubted cures in three cases (4.3 per cent.), and improvement of more than one year's duration in six cases (8.6 per cent.), while there was unquestionably no improvement in fourteen cases (20 per cent.). Surely this is not a brilliant showing. The percentage of the cured and improved together is only a little more than half as much as the percentage of non-improved. Going still further we find there are thirty-eight cases-54.4 per cent.-in which the time of observation after the operation was not sufficiently long to justify a decided opinion, though a glance at the table will show that extravagant claims were made in not a few cases. It is only fair, however, to say that in these cases there was generally an improvement, sometimes unquestionably so, though usually it was temporary. question which, to my mind, seems à propos is, How much of a probable improvement will justify resorting to so serious an operation as trephining? I know some surgeons will smile and probably throw up their hands in amazement when I speak of trephining as a serious operation, for I have frequently heard the rather flippant remark that trephining under present antiseptic conditions could not be considered dangerous. In answer to this I will only point to my table, where we find three deaths--4.3 per cent.-directly due to the operation; not a small mortality for an operation devoid of danger. The best answer which I can suggest to my question is, Never hastily decide on an operation; take carefully into consideration the patient's environment and his position in life; consider how much his epilepsy interferes with the performance of the duties. of life; how far it has been, or probably can be, controlled by drugs; then, if it is an operable case and you think the probable benefits will outweigh the risk involved, operate. When we think how few cases my statistics record when compared with all the cases that have been operated upon, we must easily see how many, many persons have been subjected to this operation when it was useless to expect benefit. It is needless at this time to call your attention specifically to cases of this kind in the table; it does not take a trained eye to detect them. How much better it would have been had these cases not been operated upon! This enormous amount of dangerous work would have been avoided, statistics would have been more accurate, and there would not be so great a preponderance of cases on the wrong side of the |