Nothing wrong about her noticed till about 19 years of age. Then, while returning home from school in a street-car, suddenly had a sensation of numbness in the left arm and hand, followed by a twitching and jerking in the left arm; then she fainted and frothed from the mouth. She was carried into a drug store, a physician called, and consciousness restored in about one and a half hours. Had a frontal headache balance of the day. Then apparently perfectly well. Attacks similar to this one occurred at intervals of two or three months till quite recently.

Became betrothed, and apparently had occasion for considerable sexual excitement, however, without satisfaction. For a short time previous to calling on me had attacks of petit mal every ten or fifteen minutes during the day and not infrequently during sleep; had also from four to ten attacks of grand mal during the twenty-four hours; had them when awake and asleep.

The attack commences with a peculiar sensation in the region of the heart, a sensation as of rapping on frontal region of head, a funny feeling in left hand (can get no definite idea), a feeling as if would lose her mind, cannot collect her thoughts. There is no rotation of head and eyes, the eyes are movable. Then the left hand, arm and sometimes the left leg are convulsed. In the lighter attacks slight twitching only, in the severe ones marked spasm and occasionally of entire body. In very few of them is there any loss of consciousness; in the severe attacks bites the tongue.

The left hand and arm have a sense of weakness; uses it fairly well, but feels that she cannot.

Bowels and general functions apparently normal. No passing of urine in conjunction with attacks.

When becomes unconscious is usually so for an hour or more. Usually sleeps well. Can not learn that immediate environment has any effect.

Physical examination revealed a sensitive spot over right parietal region; could not make out any depression, felt what seemed a small cicatrix in scalp at sensitive spot.

Examination of the eyes revealed no muscle defect, no refractive trouble and no abnormality of the disk.

The chest normal, except possibly a slight exaggeration of all sounds.

Palpation and percussion of abdomen revealed nothing abnormal.

Found no rectal or genital trouble. The muscle tone good, except in left arm, where it was markedly and generally deficient.

The examination of the urine showed nothing abnormal. Diagnosticated the case as Jacksonian epilepsy and advised opera

tion.

Prof. Knoll operated. Ether and chloroform mixture anæsthesia. A triangular flap in the scalp; on raising scalp flap found a puncture through skull about one-eighth of an inch in diameter. With chisel removed a circular button about three-quarters of an inch in diameter, and found projecting from edge of the puncture a piece of inner table projecting directly inward from skull, irregular in shape, about half an inch wide at skull and one-eighth at lower point, which was pressing directly on the dura and markedly depressing it. The dura was not torn, but was engorged and showed some inflammation, did not seem very tense, and therefore not cut.

The flap was replaced and sutured without drainage and dressed with iodoform gauze and bandage.

For some days following the operation severe headache and a great many general severe convulsions, but the unconsciousness did not last more than ten to fifteen minutes after. The convulsions were controlled by the deodorized tincture of opium. In two weeks scalp healed without suppuration and the patient was able to go home.

I saw this patient not more than three months ago and learned she was still perfectly well. She has been married, had a child, and except for a few purely hysterical convulsions during preg nancy, cured by firm moral suasion, there has been no suspicion of a

return.

Herbert C, 27 years of age; married; American. Father living, 55 years of age, always strong and healthy. In his family no history of anything that could possibly produce a disease tenof dency. No mental trouble, no dissipation. Mother 50 years age and perfectly healthy. Her family equally free from any taint.

The patient was a strong, robust boy, commenced school life at 7 years of age, continued going only in the winters till 17. Worked pretty hard on the farm and later at the carpenter trade. Bowels always regular in every respect, digestion perfect. Never had scarlet fever or any of the ordinary children's diseases. Never masturbated; sexual life very little before marriage and moderate

since. Never any venereal disease. No injury during boyhood. Married at 21.

Fell at 9 A.M., was
There was nothing

About two years ago was at work on a bridge running between two packing house buildings. It fell and threw him on a roof some twenty or twenty-five feet below, struck on right side of head and face, cut helix of right ear badly and scratched and bruised entire right side of head and face. unconscious at once and remained so till 11.30. noticed about arms or legs at that time. He remained in bed two days in a dazed, stupid condition, has very little memory as to anything during this two days. There were no febrile symptoms. Was up and about the house for about two weeks. Nothing special to keep him from going to work, but did not feel like it. Had some aching across small of the back, but not severe. Has had some dull, heavy aching across the hips and up and down the spine ever since when doing anything that caused him to bend over. Bowels have been perfectly regular since, urination regular from three to five times a day. Has had more or less bloating of the abdomen ever since the injury, but not sufficient to cause marked discomfort. Quite a little rumbling in the bowels, but neither raises or passes much gas. This is most marked after going to bed. No discomfort immediately or soon after meals. Sleeps well, regularly. No trouble with the vision.

Went to work two weeks after injury and kept at work till following August. Has not been able to do as much or as heavy work since. Has noticed particularly that he could not lift things above his head as well as formerly.

About two months after the injury, went to bed one night feeling all right; no excitement during the day; no trouble with bowels or digestion; went to sleep quickly; when awakened in the morning his wife told him had had something in the night, a spell of some kind, that lasted ten or fifteen minutes. Threw his arms around a good deal, shut his teeth very tight, breathed very hard; his wife could not rouse him. The next morning felt as usual except right arm a little lame. Some two or three months later another spell; a third between one and two months later. Then came once a month and with so much regularity could count on the night; for four months, and since last December have been absolutely regular once in two weeks.

Always sleeps right through, never knowing anything about it till wakes in the morning. Is always lying on the back when has an attack. No urination with or following. Throws the right arm over the head, turns face over right shoulder, twists the mouth to the right; cannot learn about the eyes. The arms and legs commenced to work irregularly and spasmodically, the left arm working much more markedly than the right; gets black in the face, rolls head back and forth, from direct front to as far as possible over right shoulder; eyes are wide open, the balls rolling back and forth in their sockets, then the head drawn back between shoulders as far as possible. A little blood seems to come from the nose, there is frothing at the mouth, the tongue always bitten. One very peculiar symptom, to me, at least, is that while the left arm is very much more convulsed than the right, yet it is not lame after, while the right arm will feel quite lame for a day or two.

There is some vertigo at all times when bends head over or if reads too long at a time, then eyes will feel heavy, and the letters run together and blur. The mind is not as active or as clear as formerly, the memory has failed perceptibly and there is a want of inclination to work, a feeling as though not able, yet can do a fair day's work when undertakes it.

Physical examination, going over head carefully find a spot on right parietal, where apparently a depression for which no mate. There is a slight hyperopic astigmatism, no abnormal signs in fundus, the action of all eye-muscles normal. The chest perfectly normal, except that the first sound over the mitral area is rather a clicking sound. The abdomen shows nothing abnormal. Rectum and genitals normal except a rather relaxed scrotum. Can find no evidence of any loss of power in any of the muscles. The urine absolutely normal.

After a careful consideration of the case, concluded that I could find no reflex source of irritation to which to attribute the convulsions.

That there seemed to be no predisposing cause or tendency. That preceding them there had been an injury, that the fall and manner of striking might produce such an injury as to cause the convul

sions.

That the very marked extra spasmodic action of the left arm, and always occurring in every attack, pointed toward a cerebral source.

That while ordinarily I would not, yet with the rest there was reason to suspect conjugate deviation of head and eyes to the right. That I thought I detected evidence of fracture over seat of motion for left arm.

While the indications for operative interference in this case was not as pronounced as I like, yet it seemed wise to make the experi

ment.

arm.

The patient was etherized and Professor Charles Adams made a scalp flap in form of a half ellipse, over region for motion of left Chiselled a half ellipse in bone about 13 by 13 inches; with lever, raised the freed piece fracturing at attached side. An examination of inner table revealed a perfectly smooth intact surface. Not the slightest evidence of anything abnormal. Had considerable difficulty in getting through the skull, as it was thick, very solid and hard. Found the dura tough and drawn tense. With scissors made a T-shaped incision in dura. The appearance below the dura perfectly normal, but dura seemed thicker than normal, and thicker near the centre than at either side of opening in skull. With a very fine silk gut sutured dura loosely, set the made fracture, sutured closely and carefully the scalp flap—no drainage— dressed with iodoform gauze and plaster bandage cap.

The patient suffered some headache next day, but after that, was comfortable; wound healed by first intention; no pus; bone knit quickly, and at end of three weeks seemed quite solid. Two regular times for attacks have passed without any indications. The memory is much better, and the mind much clearer and brighter. There is some evidence of ambition to go to work.

DISCUSSION.

DR. CAMPBELL: To what does Dr. Delamater credit the improvement in the last case?

DR. DELAMATER: It is a question in my mind, in some of these cases where there is not an actual fracture, if sufficient injury is produced locally by the direct contusion to set up a very low grade of circumscribed meningitis and to produce thickening, and then from this irritation lead on to the whole trouble. It is a question. I do not know. I simply know that in a number of cases where I expected to find something I have not found anything, and yet the patients get well. In other cases the patients have not got well. I report this case because I did not find any lesion such as I expected