ON THE PATHOLOGY AND TREATMENT OF EPILEPSY
793 vnfr2quently occasioning muscular retraction and articular ' I rigidity. The case of Theresa C-, in Wright's ward, is an i example in point. In this instance, a portion of the os calcis lad become necrosed, and irritation had given rise to retraction of the muscles of the calf of the leg, so that the anklejoint was held immovably fixed, and the heel was raised fully one inch from the ground. I removed the diseased bone, and the wound soon afterwards healed. The heel remained raised,
... ned raised, however; so I divided the tendo Achillis, and at length the motions of the joint were restored perfectly. It so happens that several similar cases have been operated on in the hospital Mely. --- The treatment of distortions arising from disease of the anklejoint mvoives the treatment of anchylosis; but, to avoid repetition, I will reserve what I have to say on this subject for the present. Where muscular retraction alone exists, giving rise to rigidity of the joint, with or without soft adhesions, it is necessary to divide the tendons of the retracted muscles, and gradually to restore the position of the foot in its relation to the leg by mea-ns of Scarpa's shoe or some similar form of instrument. And thus, where the muscles of the calf of the leg are retracted, causing the heel to be raised, the tendo Achillis should be divided; but where the heel is depressed, the flexor muscles, especially the extensor longus digitorum, and perhaps the tibialis anttcus and the extensor proprius pollicis, will require to be divided. Where the contraction is rectangular, it may be sufficient alone to divide the Achilles tendon. In all cases, however, of rectangular contraction with false anchylosis, where the adhesions require to be ruptured, it is necessary to divide both the extensor and the flexor ten-lIons, or those which appear to be retracted and are likely to offer themselves as impediments to the free motion of the joint, before the adhesions are ruptured. Mary C--, in Princess's ward, is a good illustration of this operation. She was admitted with false anchylosis of the ankle and knee joints. The rigid tendons around the ankle-joint were divided subcutaneously, and subsequently the adhesions were ruptured, after the administration of chloroform. The knee was operated on later. At this time the patient is in the ward, and if you examine the ankle-joints you will find scarcely an appreciable difference between the two-motion in both is perfect. And if you watch this patient walk down the ward, you will see that she walks without the shghtest limp or hesitation. I adduce this case as an example, first, because it was one of more than ordinary severity, there being two joints of a lower limb anchylosed; and also because the patient is at this time in the ward : so that the example may impress you forcibly with the value of this operation. PHYSICIAN TO THE METROPOLITAN FREE HOSPITAL. ]DURING the last few years I have seen large numbers of cases of epilepsy, 185 of which I have observed and recorded as carefully as is possible with out-patients at an hospital or dispensary. Nearly each new case increased my interest in a disease which has been looked upon with awe from the remotest times, not only from the very remarkable phenomena accompanying the disease, but likewise from the presumed inability of physicians to combat that affection. The results of my observations differ in many respects from acknowledged propositions of other observers ; but to dwell on all these points would require a good deal more space than probably can be accorded me in THE LANCET. I propose, therefore, to allude only to a few such facts as seem to me of special interest. I must premise that I am speaking of true idiopatMc epilepsy-a term which has been used vaguely; on the one hand, having been applied to many cases which were not epilepsy; and on the other hand, having been withheld from cases of true epilepsy. I think, therefore, that we should accomplish something that seems very desirable if we succeeded, in the discussion of the subject under consideration, in arriving at an acceptable definition of the disease called epilepsy. If we look over the vast literature of epilepsy, we find the definitions of the writers widely differ; but more recent authors and all writers of the, present day concur in one or two points, not such as constitute epilepsy, but the absence of which justifies the conclusion that the case is not epilepsy. These points are, perjèct loss of cOrlsciOYS7/('SS and general or partial convulsions during the attacks. "This symptom (loss of consciousness)," says Russell Reynolds, "is the characteristic phenomenon of the disease." " "We kpow," says Thomas Laycock, "that in the typical epilepsy this consists in the instantaneous and total abolition of consciousness, upon which abolition convulsions of a particular kind supervene, and the coma upon these. If there be no precedent abolition of consciousness, the convulsions are not strictly epileptic." Not only clinical teachers, but experimentalists, as Kussmaul and Tenner, Schroeder van der Ko]k, Brown-Sequard, and others, cling to these two symptoms ; and the aim of their experiments was not at all the question whether these are really the essential phenomena of epilepsy, but only how to explain them; moreover, they seem to be convinced that the condition of an animal exhibiting convulsions after cutting off the supply of blood to the brain and medulla, or after dissecting the latter, is identical with the condition of a patient suffering from epilepsy. '