the spinal marrow, much more extensive transversely in one than in the other, will produce anæsthesia in both sides of the body, but in a greater degree in the side opposite to that side of the cord where the lesion is most extensive. Reading by the light of this conclusion the cases I have reported in the preceding lecture, it will be seen that in Cases 1, 2, 4, 5, 11, 12, and 13, there was a lesion, almost entirely limited to onehalf of the spinal cord, in its cervical region. On the contrary, there was a lesion extending to both sides in Cases 3, 6, 7, 8, 9, and 10. 3rd. A lesion in one side of the spinal cord produces a paralysis of the muscular sense in the corresponding, and not in the opposite, side.-We are not much advanced yet, as regards the physiological and pathological history of the muscular sense. We do know, however, that the conductors serving to give us an accurate notion of the state of contraction of our muscles are absolutely distinct from the conductors which give us the variety of painful sensations we may receive from these contractile organs. We know, also, that in cases in which an autopsy has been made, and the spinal cord found injured or diseased in one of its lateral halves, there was no alteration of the muscular sense in the parts that were not paralysed; and as the paralysis was on the side of the lesion in the spinal marrow, it is clear that the conductors serving to the muscular sense do not decussate in that nervous centre, or, in other words, that they remain, up to the brain, in the same side of the cord to which belong the muscles from which they come. There is, therefore, a radical difference between the conductors which serve to give the peculiar kinds of sensation that belong to the muscular sense and those nerve-fibres which serve for all other kinds of sensation arising either from muscles or from joints, from the skin, or from other parts of the trunk and limbs. The conductors serving for the muscular sense behave just like the voluntary motor conductors, and seem to fol. low exactly the same course in the spinal marrow. These two sets of conductors, I repeat, do not decussate in that organ; while, on the contrary, the conductors of impressions of tickling, of touch, of pain, and of temperature, all decussate before reaching the base of the brain. I can conclude, therefore, that in the cases I have related in which the muscular sense was lost or diminished, in one side of the body (Cases 1, 2, 3, 4, and 7,) there was a lesion in the corresponding side of the spinal cord. Lectures ON ORTHOPEDIC SURGERY. The accompanying figure (Fig. 9) represents a severe form of congenital deformity; but even in such a case there is seldom found any deformity of the tarsal bones. Some of the bones deviate from their normal positions-as, for instance, the os calcis, which in such a case is drawn upwards by the violent retraction of the muscles of the calf of the leg; and in proportion as the tuber calcis is raised, so is the astragalus extruded from beneath the tibia. But the foot is also abducted; and therefore there must be a certain amount of rotation of the scaphoid and the cuboid bones, which in severe distortion always exists. This is produced by the action of the peronei. And then the foot becomes flexed upon the leg, and the anterior portion of the foot is raised, as well as everted, through the action of the extensor longus digitorum. Thus there is abduction, rotation, and flexion of the foot; and, in addition, the os calcis is elevated. In non-congenital as in congenital valgus the longitudinal and transverse arches of the foot are obliterated, so that the sole of the foot rests with its inner margin flat on the ground. At first, however, this flattening is only observed when the weight of the body is borne on the feet, as in standing: onremoving the superincumbent weight, the natural arches are, at least in part, restored. At length, however, the elasticity of the struc tures is lost, and the foot remains flat. This condition is very frequently met with in young and delicate persons with lax fibre. The tarsal liga ments in the sole of the foot yield and become elongated; and, especially under certain condi tions, the deformity may increase so much as to produce a convex surface towards the groundreversing, in fact, the natural arches of the foot, This is especially the case where much standing is required, and thus certain trades are more Talipes valgus occurs very frequently as a non-prone than others to this flattened state of the Delivered at St. George's Hospital, 1868. By BERNARD E. BRODHURST, F.R.C.S., Lecturer on Orthopedic Surgery at the Hospital. LECTURE IV. ON CONTRACTIONS OF THE LIMBS. feet. Fig. 10 is an illustration of a severe form of the hospital. It was occasioned by extensive ulnon-congenital talipes valgus. ceration on the dorsum of the foot, and by cicatrisation in healing. The illustration (Fig. 12) FIG. 12. In the second lecture I had occasion to speak of rachitic valgus. I now show you an illustration of this affection (Fig. 11), and you will obFIG. 11. serve not only the flattened condition of the feet, but also the crooked leg-bones, and the knees bent inwards. Talipes valgus also results from paralysis, the tibial muscles, one or both, having lost power. This occurs especially as a sequel of infantile paralysis. Spasmodic valgus is comparatively rare. It remains after convulsive action, which may have been excited in childhood through dental or other irritation; just as equinus may remain, or varus, or strabismus, or indeed as any other group of muscles may remain affected. In this class of cases the deformity is for the most part very severe: the arches of the feet are reversed, and the sole is convex towards the ground. The worst form of traumatic valgus that I remember to have witnessed, you also have seen; for it came under my care in shows how completely the arches of the foot were reversed, and how the foot was flexed and everted. The outer margin of the foot also was raised, and the tendo Achillis was tense; so that there was scarcely perceptible motion at the ankle-joint. Valgus, again, results from diseases of the ankle-joint itself. It is not common however, and, when it occurs, the lesser affection is lost in the greater. No one would treat eversion of the foot, when there existed at the same time disease of the ankle-joint; except in so much that it night, and probably would, be necessary to support the foot on account of disease in the articulation. Malposition, consequent upon disease, may however require to be removed: the peronei may remain retracted, and the foot in consequence. everted; or there may be, in addition, partial anchylosis of the ankle-joint. And, lastly, inflammation about the foot and ankle, by inducing softening of the ligaments, or by suppuration and loss of substance, may induce a form of valgus which is obstinate and difficult to treat. The treatment of congenital talipes valgus varies as the amount of deformity varies. Thus slight cases of valgus are occasionally met with, just as slight cases of inversion of the foot are also sometimes seen, which require no other treatment than simply the application of a bandage, to bring the foot gently into its normal position. When the tendons are rigid-indeed in all severe cases of congenital valgus, and in all ordinary cases-it is necessary to divide the retracted tendons. Whenever tenotomy is necessary in valgus, the peronei tendons require division. In a somewhat increased grade of distortion the extensor longus digitorum will also require division. The distortion should then be reduced to a condition of equinus; and eversion having been slowly and gently, but entirely overcome, the tendo Achillis, when the gastrocnemius is tense, should be divided. The foot should then be flexed upon the leg until the natural position of the limb is gradually restored. The peronei ten dons may be divided at one inch above the external malleolus, and the extensor longus and peroneus tertius as they pass over the tibio-tarsal joint. The treatment of non-congenital valgus varies also according to the degree of deformity and the cause which gave rise to deformity. A large majority of cases of valgus depends on general and local debility, and in these the form is restored by local support and rest of the limb. The general health always in these cases requires attention; the patients are usually overworked and under-fed or wrongly fed. In many, especially where the affection occurs in the young with lax fibre, a well-made boot, with a spring in the sole, together with attention to diet and limiting exercise, is all the treatment that is necessary. But when the distortion is of long standing, and structural shortening has taken place, it will be necessary to divide the peronei tendons, as well, perhaps, as the tendo Achillis. In paralytic valgus it is seldom necessary to divide tendons, except it be, perhaps, the tendo Achillis. And it is never necessary in rachitic valgus to divide any tendons. In rachitic valgus the tarsal bones undergo some change in form. The treatment in these cases is that which I have already recommended as the treatment of rickets. When rickets is far advanced, and the val gus condition of the foot is considerable-such, for instance, as is shown in Fig. 11,-it is useless to attempt to restore the arch of the foot. Spasmodic valgus being, as I have already explained, a sequel of convulsive action, it is necessary, after the subsidence of irritation, and when the epileptiform condition, or analogous state has been removed, to divide the retracted tendons and restore the shape of the limb. There is often superadded contraction of other muscles than those of the foot, the upper extremity also frequently being affected, as well as the muscles of the thigh (especially those of the internal and the posterior femoral regions); but in the foot it becomes necessary to divide the extensor longus digitorum, in addition to those other tendons which have been already mentioned. The mechanical treatment of this, as of every other deformity, should be carried on without force, so that the integument may not be injured. The treatment in many cases is tedious; but force is not necessary: the structures will yield to slow and continued extension. Allusion has been above made to a compound variety of talipes valgus, which is known as equinovalgus. This term is applied where there is somewhat more elevation of the heel, through contraction of the muscles of the calf of the leg, than is found to exist in an ordinary case of valgus. In every other respect the distortion is similar to that which has just been considered. It is unnecessary to make separate mention of the variety, except that, without this explanation, the name might cause confusion. Talipes calcaneus.-The essential characteristic of talipes calcaneus, whether congenital or noncongenital, is depression of the heel. In congenital calcaneus, the dorsum of the foot is brought more or less into contact with the naterior surface of the leg; and it is retained in this position by retraction of the flexor muscles of the foot. In this respect, therefore, talipes calcaneus is the reverse of talipes equinus. Congenital calcaneus is the least important of the several varieties of talipes; for the distortion is easily removed by manipulation and bandaging. And should it not have been removed before the child begins to walk, the muscles of the calf of the leg, which extend the foot, rapidly overcome this abnormal action of the flexors. Doubtless, however, cases are occasionally seen in which structural shorteningofthe flexor muscles has taken place, and where, consequently, operative proceedings are necessary to restore speedily the normal position of the foot. In these rare cases, the tendons of the flexor muscles require to be divided as they pass over the ankle-joint; the foot should then be supported on a well-padded, flexible splint; and, at the expiration of a week, slight, gradual extension, as in the other forms of talipes, is to be made until the normal position of the foot is obtained. Non-congenital talipes calcaneus is usually of paralytic origin: the heel drops through paralysis of the muscles of the calf of the leg. Here, therefore, as in congenital calcaneus, the heel first touches the ground in walking. The principal changes to be observed, then, in this form of talipes are depression of the os calcis, elevation of the anterior portion of the foot through retraction of the flexor muscles of the foot, and shortening of the plantar fascia; through which the sole becomes deeply arched, and the heel and the ball of the great toe become further approximated. (See Figs. 13 and 14, which show different degrees of the distortion.) In this deformity, especially when it arises from paralysis, the muscles of the calf of the leg undergo wasting and fatty degeneration. And, when the distortion is of long standing, not only are the muscles of the calf of the leg attenuated, but all the muscles of the leg will have passed into a state, more or less, of fatty degeneration. Treatment. It is seldom necessary, in the treatment of this affection, to divide the flexor tendons. The plantar fascia, however, generally requires division, and subsequently mechanical treatment will improve the shape of the limb. If, however, these cases are seen soon after distortion has arisen, not only may much deformity be prevented by the adaptation of mechanical means, but it is probable that muscular power may be in part or even wholly restored by means of stimu lating applications, warmth, and galvanism. Unfortunately, however, these deformities are often not seen until much time has elapsed, when loss of power is probably to a great extent permanent. Of calcaneo-varus and calcaneo-valgus I have to speak much in the same manner as I have already spoken of equino-valgus-namely, that they do not deserve separate mention. In the former, together with depression of the heel, there is also slight inversion of the foot; while in the latter there is depression of the heel and slight eversion of the foot. The ankle-joint.-It has already been said that valgus may result from disease of the ankle-joint. Flat-foot arising from this cause is not a direct result of disease, however; but it is consequent on the position of the limb. The motions of the ankle-joint are flexion and extension. When the joint becomes inflamed, the foot remains slightly extended upon the leg; or the foot, being supported, is maintained either at a right angle with the leg, or perhaps at an acute angle. Hence there may result, as a consequence of inflamma tion of the ankle-joint, either equinus or calcaneus or rectangular contraction. The mobility of the joint may be destroyed by true anchylosis, or it may be impaired by false anchylosis; or, again, cicatrices and adhesions may induce muscular retraction and articular rigidity. And I may mention in this place disease of some of the tarsal bones, especially the astragalus and the os calcis, as not unfrequently occasioning muscular retraction and articular rigidity. The case of Theresa C, in Wright's ward, is an example in point. In this instance, a FIG. 13. FIG. 14. cles of the calf of the leg, so that the ankle-joint 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, 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 lately. The treatment of distortions arising from disease of the ankle-joint involves 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 means 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 anticus 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 tendons, 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 slightest 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. portion of the os calcis had become necrosed, and irritation had given rise to retraction of the mus Original Papers. ON THE PATHOLOGY AND TREATMENT By HERMANN BEIGEL, M.D., M.R.C.P., 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 idiopathic 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 the facts to be derived from these figures be correct, the question arises, what is the pheno. menon characteristic and pathognomonic of epilepsy? Patients who fall down, losing their senses, but lying perfectly quiet, without the slightest convulsive movement, are by no means uncommon. Others tell us that they are over-powered by some remarkable feeling, dragging or throwing them more or less violently to the ground, and state positively that, though unable to speak, yet they are aware of everything around them. Convul sions and loss of consciousness, therefore, cannot be considered as essential symptoms of epilepsy, though present in by far the larger number of cases. 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 But I have never met with a patient whose present day concur in one or two points, not such friends or relatives had not noticed the phenoas constitute epilepsy, but the absence of which menon characteristic of epilepsy-namely, abnorjustifies the conclusion that the case is not mal actions of the circulating system. In every epilepsy. These points are, perfect loss of con- case I learned that the patient was either deadly sciousness and general or partial convulsions dur- pale or red-that the lips were blue, or the face ing the attacks. "This symptom (loss of con- and whole body dusky. A patient is still under sciousness)," says Russell Reynolds, "is the my care who, when sitting at the dinner table, or characteristic phenomenon of the disease." "We when playing at chess, suddenly becomes deadly know," says Thomas Laycock," that in the typical pale, dropping things out of his hands, remaining epilepsy this consists in the instantaneous and motionless for a few seconds or a few minutes, total abolition of consciousness, upon which being unable to speak, but knowing more or abolition convulsions of a particular kind super-less distinctly what others do and say. These vene, 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 Kolk, BrownSéquard, 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. Pathological anatomy rendering us very little assistance in the study of epilepsy, clinical facts must of necessity be of more weight than experiments, which, valuable and interesting as they are, cannot pretend to show anything but the wellknown fact, that certain lesions of the brain and medulla are likewise liable to produce epileptic phenomena. Now what do the clinical facts teach us? It is not at all rare to see a patient suffering from epilepsy without having any visible convulsions in the fits. Another patient may have convulsions, but no loss of consciousness; and, what seems perhaps most remarkable, a patient may be an epileptic, and have fits, and severe fits too, without exhibiting in them visible convulsions or loss of consciousness. symptoms occur, sometimes once, sometimes sev eral times, during the day; and when they disappear, leave the patient sleepy. Another patient had the same symptoms, but has been several times thrown to the ground. Now this, I think, is epilepsy in the truest sense of the word, although neither convulsion nor loss of consciousness is present; and I must add that it is a very bad and disagreeable form of epilepsy. These observations, in connexion with the fact that no abnormal action of the heart can be discovered during the epileptic fits, justify the definition of epilepsy as a disease the characteristic clinical features of which consist in abnormal contraction or relaxation of the bloodvessels, independent of disease of the heart, recurring at intervals, during which the patient, as a rule, enjoys good health. This definition includes partly the "new sense" in which Dr. Hughlings Jackson wishes to see used-or, as he expresses himself, degraded-the term epilepsy. But it differs in the most essential point, since Dr. Jackson wishes to use the term to imply the condition of nervous tissue in sudden and temporary loss of its functions. If we adopt this proposition, then of course Dr. Jackson is right in saying that it must hold some such place as or y in an algebraical problem. I am in possession of the history of cases which show the very commencement of the disease, going through a large number of stages, |