HALLUX RIGIDUS.

MR. J. M. COTTERILL ON HALLUX RIGIDUS.

129

oblivion of the events of the day in question, together withsatisfied as to the general accuracy of the account. The the general features of the case, led me to negative the case was that of a clergyman. As regards his previous history, view that it was an imposture and to report that in my at the age of thirty he temporarily lost his sight and hearing, opinion she was not responsible at the time, The question apparently from religious excitement. He had been subject as to whether it was a hysterical or an epileptic phenomenon to headaches and to temporary fits of depression. There was is extremely difficult to decide. There was strong evidence no definite history of epilepsy, but he has had "several spells of hysteria in the previous history of the case, but such of unconsciousness " lasting a few minutes, which may have periods of unconsciousness in hysteria are in this country, been of this character. On June 17th, 1887, he drew over He then so far as I am aware, unknown, although cases have been ;E100 from a bank to pay for a certain plot of land. described, mainly in the south of France ; but the nature of got into a tramcar, and this was the last incident he rememmany of these is to my mind epileptic rather than hys- bered. He was not heard of for two months although adverterical. The positive evidence of any epileptic tendency in tised in the papers as missing and sought for through the this patient was slight, and consisted chiefly of the numerous police agencies. On the morning of March 14th, at a place convulsions from which she suffered in infancy. It is at least 300 miles away, a man calling himself A. J. Brown, possible that the spells mentioned by her husband were who had rented a small shop six weeks previously and stocked periods of automatism after unobserved attacks of petit mal. it with stationery and small articles, and carried on the trade The grotesque character of her performance, the sudden without seeming unnatural or eccentric, suddenly "woke awakening, and the (apparently) complete oblivion subse- up " in a fright and called upon the people of the house to quently correspond closely with the phenomena met with tell him where he was. He said that his name was -, after epileptic fits. There is insufficient evidence to allow that he knew nothing of -, was entirely ignorant of shopone to speak dogmatically, but I should regard the case as keeping, and that the last thing he remembered (it seemed He soon one on the borderland between epilepsy and hysteria, and yesterday) was entering the tramcar at the epileptic element as the essential factor in producing the proved his identity. He was very weak and exhausted, and automatism. It was my intention to hypnotise the patient had lost ;E20. During the six weeks no allusion to his in order to ascertain whether in the hypnotic condition she former life could be traced, except that he once gave an would remember and describe what had happened during address at a prayer meeting as Brown in which he related the period of automatism. This has been successfully an incident which he had witnessed in his natural state. accomplished in some cases (see later), and the account The fortnight, however, which transpired between his verified. Unfortunately, I was prevented from carrying out leaving the one place and his arrival at the other remained the test in this case. unaccounted for, and in the hope of obtaining some inforOne of the most remarkable of these cases of prolonged mation on this point he was hypnotised three years later. automatism in which no epileptic element could be definitely In the hypnotic condition he answered at once to the traced is fully described by Charcot.6 The patient was sober name of Brown. He said " he had heard of (his and well conducted and had been under observation for some correct name), but did not know that he had ever met the time. The accounts he gave of himself were in many cases man," and when confronted with his wife he said emHe was first seized phatically that he "did not think that he had ever met corroborated by independent inquiry. with an attack when thirty-four years old. He lost con- the lady before." When questioned he at once recounted sciousness when walking in the street at 8 A.M. He knew his doings in the "lost fortnight." He had spent an afternothing more until 10 P.M., fourteen hours later, when he noon in Boston, a night in New York, and ten days in Philafound himself still in Paris, footsore, hungry, and tired, and delphia, first at an hotel, afterwards at a boarding-house. he was unable to work next day. He continued to have The proprietors of the latter remembered him quite well and similar unconscious "wanderings," lasting some hours, at said that he was very quiet, occupying himself chiefly with intervals of three or four months, until at the end of two reading, and talking little, and that he never seemed to be at years he had one which lasted eight days. He was delivering all odd in his actions. He could not be induced to confuse goods in Paris for a firm in that town which employed him, the two existences. No account has yet been given (so far and he had a considerable quantity of money about him, as I am aware) of the subsequent progress of this case. when about 7.30 P.M. he lost consciousness, and as he did Although one may, perhaps, venture to take one or two of not return the driver of the van he was with drove off with- the details durn grano salis, the dual existence which is out him. Eight days later he suddenly "woke up " on a shown in this patient’s case is extremely striking, especiin a strange town, which, on inquiry, he found ally as one has the benefit of the evidence of independent to be Brest. His clothes and boots were in good order, witnesses as to his conduct during the two months that so that he had probably stayed at an hotel. On exa- the attack lasted. The question arises whether, in cases of undoubted mining the contents of his pockets he found that he had spent £8 out of the 40 of his employer’s money with epileptic automatism, there may be a similar condition of which he started. He was about to send a telegram to dual personality. At present I have been able to find no. his employers, when the unlucky notion entered his head clear evidence on the point. Occasionally, and particularlyto consult a gendarme.. This official promptly took him into in the simpler cases, a repetition of the same act is foundcustody, and the magistrate remanded him to the cells for a e.g., attempting to undress ; but I have not yet met with, week and would not grant him permission to see a medical cases in which patients acted definitely as if they had lost. man although he had a certificate from M. Charcot detailing their own personality, as was the case with the American his liability to these attacks. At the end of a week he was clergyman. It will, however, be desirable in cases where, liberated by the intervention of his employers. How he spent the automatic actions have led to unpleasantness or to false: the eight days was never cleared up. (There is no mention charges to hypnotise a patient, as the information so. of his having been hypnotised subsequently.) Although there obtained, though of course in itself worthless as evidence,, was no history of epilepsy in this case M. Charcot held may lead to facts being brought to light which would not strongly that it was of this character, and this was so far otherwise have been forthcoming. For merely experimental confirmed by the marked influence of bromide of potassium purposes I should not, however, at present feel justified in in diminishing the frequency and duration of the attacks. hypnotising such patients. Before the long attack described above, the administration of Wimpole-street, W. bromide had unfortunately been suspended for some time. A similar case is reported by Motetin which a patient sufferHALLUX RIGIDUS. ing from traumatic epilepsy used to have similar wanderings after the fits. On one of these occasions on "waking" he BY J. M. COTTERILL, M.B., C.M., F.R.C.S. EDIN., found he had been unconscious for over a week, that he had LECTURER ON CLINICAL SURGERY IN THE EDINBURGH SCHOOL OF had been as far as Nice, and spent £60. MEDICINE; EXAMINER IN CLINICAL SURGERY IN THE UNIVERSITY The most interesting and important case in this connexion, OF EDINBURGH. owing to its duration and the subsequent behaviour of the patient when hypnotised, is quoted by Professor Jamess (for the THE article on hallux rigidus by Mr. Mayo Collier in reference to which I am indebted to Dr. Hughlings Jackson). THE LANCET of June 30th is of special interest to me, for it He says that the facts have been investigated by, among in confirms the views which I expressed in a many respects others, so high an authority as Dr. Weir Mitchell, who was paper read before the Edinburgh Medico-Chirurgical Society 6 du Mardi à la Salpêtrière, 1889. Leçons in 1887. An abbreviated report of this paper may be found 7 Ann. Med. Psych., 1886, p. 128. 8 Principles of Psychology, vol. i., p. 391. in vol. vi. of the Society’s Transactions, p. 277, and in 1887 I -.

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MR. L. A. BIDWELL ON THE RADICAL TREATMENT OF LUPUS.

130

" a brief note 1 the term " hallux rigidus for this cause flat-foot, as a matter of daily experience I know that i is far otherwise. And how does the theoretical objector condition. The opinions which I then expressed were con- it trary to those of other correspondents at the time ; but as propose to explain the flat-footed negro ? 8. While there is the nomenclature and pathology which I then suggested haveno reason why gout, rheumatism, rheumatoid arthritis, traugradually found their way, in a more or less mutilated form,matism, &c., should not occasionally cause stiffness in this into common use, it may perhaps be as well to shortly repeatjoint as in others, these conditions have no primary causative my propositions, though it will be hardly possible in so shortrelation whatever to true hallux rigidus. a paper to prove my contentions. Treatment.-In all but the severest and most neglected 1. Hallux rigidus, properly so-called, consists of ancases all that is required is to stretch the shortened ligainability to fully dorsiflex the great toe on its metatarsalments and break down any adhesions, if necessary under an bone. In health it can be dorsiaexed to a right angle ; any anaesthetic ; then keep up the gained power of dorsiflexion limitation of this range of movement must be considered as by daily passive movement; and firm pressure will be including the case in the class, but it is only in aggravatedrequired for this purpose to overcome muscular spasm in cases where dorsiflexion is entirely, or almost entirely, the flexors. In addition, the flat-foot must be suitably abolished that discomfort is caused and the surgeon con- treated by tiptoe exercises, massage to the calf muscles, sulted. 2. Hallux rigidus is never caused by flat-foot alone, supports, &c. ; but into this part of the subject I must not though always associated with it. It occurs in flat-footed enter at present more fully. I have found this treatment patients who wear such boots as prevent the angle of 30° sufficient after a few days in almost every case to enable the (or thereabouts) which normally exists between the first patient who, it may be, limped into hospital in great pain, to metatarsal bone and the first phalanx, being maintained when walk any distance in absolute comfort. There are a few oldthe base of the metatarsal passes downwards in the falling of standing cases with firmer ankylosis, where removal of the the instep in flat-foot. Strictly speaking, the great toe is base of the first phalanx may be necessary. This proceeding not flexed on its metatarsal bone, but the metatarsal i?, so to (recommended by Mr. Davies-Colley in 1887) is preferable, in speak, flexed on the great toe ; and therefore I objected to my opinion, to interference with the head of the metatarsal the term"hallux flexus," which was proposed by Mr. Davies- bone, as being less likely to interfere with the tripod strength Colley, as misleading in pathology. This term should be of the foot. I have done this operation in one case with a restricted to those rare cases of pure plantar flexion of the perfect result. Where such an operation is not permitted, hallux due to contraction of muscles from spinal or other and the case is beyond the reach of the milder means detailed I have seen two such above, the patient can be made to walk comfortably, though causes and unassociated with flat-foot. cases, and they were both cured at once by tenotomy. 3. That with a somewhat awkward gait, by adopting Professor hallux rigidus is never caused by flat-foot alone is proved by Chiene’s plan of inserting a rigid metal plate in the whole the fact that negroes, who are very commonly flat-footed, length of the sole of the boot, so as to prevent any possible strain on adhesions or shortened ligaments in attempts at never suffer from hallux rigidus unless they wear boots. Their unrestrained big toes turn upwards when the instep dorsiflexion in walking. This treatment is of course merely falls and the normal angle of 30° above mentioned is palliative, as it perpetuates and does not cure the stiffness, preserved. The clodhopper’s boot, the French sabot, and though it certainly entirely removes the pain in walking as other varieties of boot are, by a sensible arrangement dic- long as the plates are worn. tated by experience, purposely made so as to allow of this Manor-place, Edinburgh. necessary dorsiflexion of the great toe ; and therefore in people who wear such boots the condition is not met with. The ordinary strong boot of the town boy is the one which, in the presence of flat-foot, causes the disease. 4. While, as THE RADICAL TREATMENT OF LUPUS.1 in other painful joints, a certain varying amount of the BY LEONARD A. BIDWELL, F.R.C.S. ENG., stiffness may be due to muscular spasm (as can be verified SENIOR ASSISTANT SURGEON TO THE WEST LONDON HOSPITAL, ETC. if the patient be anaesthetised), the essential reason for the loss ofdorsiflexion is contraction of the inferior portions of AFTER considering the pathology of lupus and its behaviour the lateral ligaments of the joint. This portion of the ligament is slackened when (the toe being fixed by the boot) after all other methods of treatment the conclusion must be the instep falls. It consequently in time becomes con- arrived at that a complete and free excision, involving the tracted ; whereas the superior ligamentous structures are whole thickness of the skin, is the ideal treatment. Until put on the stretch, sometimes to such an extent as to cause possible in the case of small pain. The upper part of the joint surface on the dorsal aspect recently excision was only of the metatarsal head no longer takes part in the work of the patches of the disease where the edges could be brought together with sutures after the operation, for the tediousness joint ; it consequently becomes altered, eroded, lipped, &c., of healing by granulation and subsequent cicatricial conas is often seen in joints elsewhere under similar conditions. The glenoid or plantar ligament can have little to do traction prevented such treatment for patches of any with the matter, for it is fibro-cartilaginous and its fibres considerable size. The combination of immediate skin graftrun transversely ; therefore its power of contraction must be ing after Thiersch’s method with free excision enables the trifling. 5. When the instep falls of course the foot surgeon to radically treat patches of lupus of any size. lengthens along its inner margin. The big toe is thus thrust Small parts of a patch were treated in this way by Professor forward (constituting the "abnormally long great toe" of Thiersch in 1889, but he took five or six sittings to complete the remQval of the lupus. I believe that Mr. Watson Cheyne some writers) and impinges at every step against the end of the boot. In this way additional irritation is probably was the first to perform such an operation in this country, caused in the joint, synovitis follows, adhesions form, and and some of the first cases so treated were shown at the 6. The condition is frequently Medical Society of London2 in March last year by Messrs. the stiffness is increased. bilateral ; it occurs generally in young males from twelve to Watson Cheyne, Bruce Clarke, and myself. At the meeting twenty who have a lot of standing or running about to do, of the British Medical Association at Newcastle I communisuch as errand boys ; in other words, in exactly the same cated a paper on this treatment for lupus,3 and I think class in which flat-foot is so common. It occurs occasionally, that many surgeons have now given it a trial. With regard but not nearly so often, in females. It is naturally associated to the operation itself, one of the most important factors with the same want of muscular and vascular tone which one in its success is a very strict attention to antiseptics ; finds in flat-foot. 7. Mr. Mayo Collier says the condition is a this is the only way to ensure the vitality of the extensive comparatively rare one. I should call it a very common one. skin grafts. The lupoid patch and surrounding skin should It can be frequently seen in any of our large infirmary be thoroughly disinfected on the day before the operation, out-patient rooms, and I have no hesitation in saying that and a "packing" of gauze soaked in 1 in 20 carbolic acid I have seen scores of cases in the last twenty years. solution should be kept on all night. The part from which the Perhaps this may be due to the fact, which may surprise grafts are to be taken should be similarly prepared. The patient must be placed under an anaesthetic, and an incision is made some of my readers, that the children of the lowest class in the slums of Edinburgh, even in the present year of grace, down to the subcutaneous fat all round the lupus about a generally run about without boots ; and though I am well quarter of an inch from its margin. The whole thickness of the aware that on theoretical grounds it may be objected that This paper is part of a post-graduate lecture delivered at the West the free play of the bare foot ought to prevent rather than

proposed in

1

London Hospital.

1

Brit. Med.

Jour., May 28th, 1887.

2 THE 3

LANCET, March 18th, 1893. Aug. 19th, 1893.

THE LANCET,