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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.

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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
OF EPILEPSY.

By HERMANN BEIGEL, M.D., M.R.C.P.,
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 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.

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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,

and arriving at that form or degree which has generally been regarded as the representative of epilepsy par excellence.

From the definition given, I need scarcely say that I consider epilepsy as a disease of the vasomotor nerves; which, according to the teachings of physiology, are in a constant state of moderate irritation, the diminution of which produces enlargement of the blood vessels, while an increase will cause contraction of them.

This view of the nature of epilepsy has already been presumed in respect of many cases of that disease by two well-known continental experimentalists, Drs. Landois and Eulenberg; and my observations are nothing but the clinical evidence for their presumption, applied to epilepsy in general. As in other nervous affections, so in epilepsy, it is by no means necessary for the whole system of the vaso-motor nerves to be implicated in the change which results from some irritant, peripheric or central; but the change may take place in certain branches or districts, or some branches or groups may be more affected than others. This fact gives an explanation of cases like the one recently under my care at the Metropolitan Free Hospital. The patient was a blacksmith, very strong, and apparently healthy. Several times a day he changed color, becoming very pale, and at the same time being unable to articulate; while he felt a peculiar sensation arising in his right thumb, and moving along the arm and neck. The right arm was then convulsed, and the right side of the face distorted. This lasted for about three or four minutes, sometimes only a few seconds; during which the patient retained consciousness, trying to speak, but being unable to utter anything but a few inarticulate sounds. He never had any other fit. Such cases have been called "petit mal," "epilepsia abortiva," &c. But this is as little justifiable as it would be to apply another name to the contraction of one muscle or of a few muscles than is given to the same affection if existing in larger proportions. The same may be said of all inflammatory and many other diseases.

The change produced by the vaso-motor nerves may be limited, indeed, to a very small areafor instance, to the muscular layer of the vessels supplying the retina; so that, in this sense, it is quite justifiable to speak of "epilepsy of the retina" without being exposed to the jocose question put to Dr. Jackson, whether the retina are subject to convulsions. A closer study of the disease, from the point of view which I propose, will also throw more light on the phenomenon which is generally called the aura. It is not very long since epilepsy was not considered legitimate, if not preceded by an aura. But if we seek for information on that phenomenon, nearly every author includes other symptoms in the term. I must here state, in opposition to the generally adopted opinion, that the sudden appearance of paroxysms is a rare exception; as a rule, the attacks are preceded by certain changes, indicating altered conditions either in the vaso-motor or in the sensitive nerves, giddiness, loss of speech or sight, undue irritability, alteration of features, numbness or hyperæsthesia, &c. Of these changes the patients are very seldom aware, but the patients' friends notice them.

Of 137 cases in which I have been able to

gather information on that point, the result is as follows:

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14 cases. 94

An aura was present in
Precursory symptoms in ...
Sudden commencement of attacks in 29 "9
137 cases.

The term aura ought to be confined to sensations arising at a particular part of the body, and being characterised by their tendency to move towards the nervous centres.-All other sensations, limited to certain parts, or affecting the whole body, have been noted down by me as premonitory symptoms. These, as well as the aura, must be considered, as has been done by many authorities, as the commencement of the paroxysm, which, in the majority of cases, I think, would be noticed hours before its perfect development, if the temperature of the patient were measured. Epileptics not being admitted as in-patients to general hospitals, it would be not only an interesting but very important task if gentlemen connected with asylums could find time to extend their researches in this direction-a field of investigation which, so far as I am aware, has not yet been cultivated.

Not being able to touch on many points of interest connected with epilepsy, before I say a few words concerning the treatment of the disease I may be permitted to allude to one point of great importance, namely, the hereditary taint. Of 168 patients, this condition could be traced in a direct line-viz., grandparents, parents, brothers, and sisters, in 61; in an indirect line-viz., first cousins in 6; and in 101 no hereditary transmission was traceable. The interesting point here is, that the hereditary taint sometimes shows itself immediately after birth; in other instances it disposes the individual in such a manner as to give rise to epilepsy or allied diseases, through causes which would be of little or no consequence at all if the inherited disposition were not present, the latter thus remaining latent until something occurs-pregnancy, fright, shock, or injurywhich, in an individual of an epileptic parent, produces epilepsy, chorea, or some similar disease. There are still some members of a family under my care at the St. Pancras Dispensary showing this condition in a remarkable manner. The father, forty-nine years of age, has had several tits a day for the last twenty-five years. Of his two sons, the eldest, aged twentythree, had two fits, the first only seventeen months ago, when he was much excited by attending his father in a fit; the second fit came on in April last. The younger son, seven years old, has been, and is at present again, suffering from chorea. Of the three daughters, the eldest, twenty-four years of age, has been suffering for years from fits, without always falling down; the younger daughter, twenty-two years old, had not been attacked until she was fourteen. At that time her father burnt his arm, and her mother was dressing the wound; the patient was looking on and fell down in a fit, which did not recur. At seventeen, she married, and soon became pregnant, when quickening, she was again attacked, and until delivery the fits occurred about four times. She had had three children, and at each pregnancy she knew that she was quickening merely by the occurrence of a fit, for she never felt any movements of the foetus. In her non-pregnant state she enjoys excellent health. The youngest daugh

ter, eighteen years, is strong, complaining only now and then of violent headache, which lasts for weeks.

Another interesting case is under my care at the Metropolitan Free Hospital. The patient is a lad of seventeen, a butcher by trade. His grandmother died in a fit, and his sister became insane after a fall when four years old. Patient is very strong, and enjoyed good health until a few days before he came under my care, when he was frightened by seeing his grandfather, who was insane, jumping out of the window; soon afterwards patient was seized by a fit, which recurred several times.

to be cured because the fits do not make their appearance for several weeks, then we may rest assured that such an author has other motives in publishing his case than that of advancing science and serving the truth.

In the majority of cases the physician is able to improve the patient's condition, in a great measure, by turning very long fits into slight ones, or by causing the interparoxysmal time to be much longer. Mr. Barry, late house-surgeon of the Metropolitan Free Hospital, has watched a case with me, which was of very great interest in a therapeutical point of view. The patient was a woman aged forty-eight. Six years ago she had A few days ago only another interesting epi- been attacked with fits, and had "scores" of them leptic family case came under my care at the hos- every day-at least twenty in twenty-four hours. pital. The father, forty-five years old, had fits During the whole six years she was only once until about ten years ago. Of his four living free of them for four days. She must, therefore, children two are daughters and two sons. All have had at least 6000 fits altogether. When I four were much convulsed when teething. The first saw her she had an attack in my consulting elder daughter had fits from her fifth year until room, and I confess it was the most terrible attack seventeen, when she became regular and lost her I have ever witnessed. She was treated by means fits. The younger daughter, seventeen years old, of hypodermic injections of morphia, and in the has still fits, but is not yet regular. The elder son, week after the injections she had only one attwenty years old, is likewise subject to fits, but tack. The injections were repeated twice a week, they only set in on certain occasions; as, for in- and when the attacks were turned into "faintstance, when he is beaten by his father, an occa- ings," as the patient called them, which recurred sion which seems to occur rather frequently. about three or four times a week, and did not He never has a fit without a demonstrable cause. cause her to fall, she did not return to the hospital There are other interesting points connected any more. with epilepsy, as, for instance, the influence of age, sex, &c., on the development and course of epilepsy. But these points, I think, cannot be studied in hospitals, in which the attendance of certain kinds of diseases depends on a combination of artificial, as it were, not natural, causes. The statistics given on such points by different authors have, therefore, no claim to much weight. Of my own cases 82 were men and 100 women. Are we to infer from these figures that epilepsy is more frequent in women than in men? Is the conclusion not equally justifiable that women are much more inclined to seek medical advice in hospitals than men, who do not consider it worth their while to lose at least a half-day's work weekly by attending a hospital, if the attacks occur only once or twice in the course of a year? If mortality be a measure of the prevalence of a disease, the statistics of the United States of America do not bear out the opinion generally adopted of women's greater liability to epilepsy than that of men. During the year ending June, 1860, 501 persons died of epilepsy in the United States. Of these 284 were males and 217 females. I have carefully looked over the most excellent tables, prepared by the Government of Washington, and find the same proportion in all ages, in all provinces, and through all the twelve months of the year. It is, perhaps, not without interest to mention that in the States in which slavery had existed the number of deaths from epilepsy was considerably smaller than where slavery had been abolished.

A few words, in conclusion, with respect to the treatment of epilepsy.

There is, perhaps, no other disease in which the physician can do more good to his pa. tient than in epilepsy. In many cases he is able to effect a cure, by which term I mean the patient's not having fits for years. If we see cures of epilepsy every week published in the journals, and see further that some writers fancy the patients

Of the whole number of my patients, 46 remained sufficiently long under treatment to warrant an opinion of the efficacy of the drugs applied. Of the number just mentioned, 14 were cured, 26 have improved, while in 6 the treatment had no effect. A case which I am inclined to look upon as cured is the following:-The patient was twenty-one years old, a shoemaker by trade. The grandfather had several fits, but the patient was in good health until three years before he came under my care. At that time he came up from the country, in order to see an execution at Newgate, which made such an impression on him as to bring on epileptic fits after a few hours. In these fits he lost consciousness, and was very much convulsed. For two years he was sometimes free from paroxysms for sev eral months, and then again he had several attacks in the course of a day; six months, however, before he was admitted an out-patient to the hospital, he was seized several times every day. He was likewise treated by means of hypodermic injections of morphia, which were continued for a long time. After having been free from attacks for about twelve months he requested me, in 1865, to discharge him,in order that he might go in search of employment. A few months ago his father came to the hospital, and from him I learnt that his son, who is now in the country following his trade, had never had a fit since he left the hospital.

As to the remedies used by me for the treatment of epilepsy, I have tried nearly all drugs which have been recommended by different anthors, including urari or the arrow-poison of the Indians, so strongly recommended by a few continental physicians, which, however, has failed in my hands.

But there are two drugs in which confidence may be placed, viz., bromide of potassium and hypodermic injection of morphia. It is now a well-known fact, that the former when used in

very large doses has the power of postponing the
paroxysms, and in some instances to make them
disappear altogether. Hypodermic injections
have the power of producing the same result in a
much shorter time. It is very difficult to explain
why the action of morphia is different when
given internally and when applied hypodermi-
cally, but that such is the case has been confirmed
by reliable observers.
Finsbury-square, Dec. 1868.

to renounce the old-fashioned term "vital force;" neither am I prepared to admit that it is but a correlative of those grand forces the study of whose relation to each other has so deservedly captivated the scientific world. This would be tantamount to acknowledging that, as practitioners, we have only to discover and treat morbid lesions, and that this is to be done without reference to the general condition of the patient. I do not in the least disparage the inquiries of those who have investigated this subject from a purely chemical or chemico-mechanical point of view. Those researches have been ably con

COD-LIVER OIL AS A REMEDIAL AGENT ducted, and rich and fruitful gleams of light have

IN TYPHUS.*

By ROBERT GEE, M.D., M.R.C.P.,
Physician to the Liverpool Fever Hospital, Lecturer on
Diseases of Children at the Liverpool Royal Infirmary.

In taking a survey of medical science, we are impressed with the difficulty, if not the impossibility, of defining its true progress with anything approaching to accuracy. That great advances have been made within the present century, in regard to the nature and treatment of disease, is undoubted; but it is also true that there is still much uncertainty remaining. Facts have been accumulated and recorded, but they have been variously interpreted. Theories have been advanced, which in their turn have been abandoned. Hence the difficulty of formulating, at any specified time, the exact position of the science.

been thrown upon an obscure page of pathology by their efforts. I must, however, state it as my opinion that their sphere of vision has been too limited; that, while they contemplated their object, and thought they had embraced the whole circumference, they have in reality seen but one portion.

It is stated by the same eminent physician that "excess of chemical action originates some of the most serious diseases to which the body is liable," and that "the first chemical wrong action sets up mechanical derangements which again become the secondary causes of further more or less serious chemical errors." I grant that there is much truth in the theorem, but cannot give my adherence to the statement as representing the whole truth; for we daily witness and experience the influence of a controlling power, call it what you may, repressing or moderating the action of external agencies, which, uncontrolled, would inevitably terminate in disaster.

Let me take, for example, the important subject of inflammation. Various theories have been promulgated with regard to its nature, which it is not necessary for me to allude to as they are familiar to all. But of late it has been generally admitted that inflammation, in its origin, is either ascribable to a perversion of nervous or vascular" action, or that, in its essence, it is a modification of nutrition, the result of a morbid change in the relation existing between the textures and the blood. This view, however, has lately been combated by an author of no mean note, who broadly asserts that it a purely chemical disease, that "in its origin it is an exaggeration or excess of the ordinary oxidising action that occurs in each part of the body, and that this increased chemical action sets up secondary mechanical derangements which react on the chemical repair of the textures in which the inflammation is set up."

We have been accustomed to regard the changes which take place in an inflamed part as physical or chemico-physical, influenced, nevertheless, in no small degree by a power which has been termed vital force; but in the chemical theory just referred to we are called upon to renounce our old opinions-to deny the existence of vital force, that mysterious power which, intelligently gauged and recognised as unimpaired, has been a source of confidence to the practitioner both in medicine and surgery, in times of difficulty, when otherwise the forebodings would have been dark and gloomy.

Viewing the subject from a chemical standpoint, I am not as yet prepared to deny the existence of this obscure and powerful agency, and A paper read at a meeting of the Liverpool Medical Insti

tution.

I pass on by an easy passage from the subject of inflammation to that of fever. The same author holds a similar view-a chemical onewith regard to the essence of fever. He places it in the category of diseases which he designates as diseases of modified peroxidation. The term zymotic," which was originally applied by Dr. Farr to a certain class of disorders, was probably not intended by him to convey the idea that the essence of those diseases consisted in the setting up of a chemical process-fermentation solely, though the word bears significant relation to chemical action; but Dr. Bence Jones takes advantage of the true meaning of the term, and applies it to illustrate his view that fever is neither more nor less than a chemical process in which oxygen, organic matter, and a specific ferment are the elements involved. The theory is simple and attractive, and also true up to a certain point; but, in my opinion, it does not embrace the whole truth, for the fact that this process is set up in a living entity is entirely ignored. That there is in the system a vis, which in some cases moderates this chemical action, and in others entirely prevents it, is a fact which appears to me to be incontrovertible. I may refer to the experience of the attendants at our fever hospitals as proof of the accuracy of the statement. The same oxi. diser, the same organism, and the same ferment may be in close proximity for a long period of time without any chemical action taking place: but under the influence of some powerful moral or mental agency or over-fatigue, depressing the vital power, the fever process is originated, and, when once set up, rests not until the whole sys tem is implicated. I see no objection to the term " modified per-oxidation," were it understood

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